Consent For Release Of Confidential Information
Date Sent/Mailed: Student's Name: DOB: School: Grade:
We are asking that you authorize the person or agency named below to release specified records containing confidential information regarding the above named student:
Information Requested From: ______________________________
Send Requested Information To: ______________________________
Records requested: [ ] Medical/health history [ ] Reports
Purpose of disclosure: Assist in providing appropriate health care in the school setting.
Please check Yes only if you agree that the statements are correct. If the statements are not correct, check No. If you wish to have more information or if you have any questions, please call ___________________________________________ at _____________________.
Yes No [ ] [ ] I have been fully informed and do understand the school's request for my consent for release of my child's records, as described above. This information will be released upon reciept of my written consent. [ ] [ ] I understand that my consent is voluntary and may be revoked in writing at any time.
________________________________ _____________ Signature of Parent/Guardian Date ________________________________ _____________ Signature of Interpreter, if Used Date
Please send requested information to the address above as soon as possible.
[ Back to Table of Contents | Prev Section | Next Section]
Last Updated: Thursday February 27, 2014 19:28:21
This Internet site provides information of a general nature and is designed for educational purposes only. If you have any concerns about your own health or the health of your child, you should always consult with a physician or other health care professional.
This site is published by T-1 Today, Inc. (d/b/a Children with Diabetes), a 501c3 not-for-profit organization, which is responsible for its contents. Our mission is to provide education and support to families living with type 1 diabetes.
© Children with Diabetes, Inc. 1995-2016. Comments and Feedback.