advertisement
 

  Back to Diabetes Management at School Consent For Release Of Confidential Information

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:     ______________________________

______________________________

______________________________
spacer
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    
spacer
[  ]  [  ]  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.
spacer
[  ]  [  ]  I understand that my consent is voluntary and may be revoked in writing at any time.



________________________________   _____________
Signature of Parent/GuardianDate
spacer
________________________________   _____________
Signature of Interpreter, if UsedDate

Please send requested information to the address above as soon as possible.

[ Back to Table of Contents | Prev Section | Next Section]



                 
  Home Return to Top

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.
By using this site, you agree to our Terms of Use, Legal Notice, and Privacy Policy.
© Children with Diabetes, Inc. 1995-2015. Comments and Feedback.