Salem Keizer School District - Authorization to Use or Disclose Protected Information

Authorization to Use and/or Disclose Educational and Protected Health Information

I authorize the following provider(s) to use and/or disclose educational and/or protected health information regarding my child.
Student/Child’s Full Legal Name*
Other Names Used by Student/Child
Child Date of Birth*

MonthDayYear
Date
School or Program Name*
Name and address of health care provider authorized to

Send/disclose protected health informationSend/disclose educational informationReceive/use educational informationReceive/use protected health information
Medical Clinic Authorized to Speak to
Sensible Speech & Rehab 1475 Capitol Street NE, Salem OR
School Name*
I understand that this information will be used for the following purposes (check all that apply):*

Determining eligibility for Special Education, EI/ECSE, or other servicesDeveloping an appropriate Individualized Education Program or Individualized Family Service PlanDetermining student/child’s current levels of performanceDeveloping an individualized health planOther
By marking the boxes below, I authorize the use/disclosure of the following specific medical and/or educational records*

Physician’s Eligibility StatementEducational InformationPsychological evaluationsHealth Assessment StatementIFSP/IEP documentSocial work reportsHistory and physical examClinic recordsPhysician treatment ordersEntire medical recordCommunicable disease(s)Prenatal informationProgress notesOther
By initialing the spaces below, I authorize the use/disclosure of the following information. Specific records requested must be listed below, e.g. assessment, treatment plan, discharge plan.
Initials
Drug/alcohol diagnosis, treatment or referral information requested
Initials
HIV/AIDS related records requested
Initials
Mental health related information requested
Initials
Genetic testing information requested
I understand that:

a. This authorization is voluntary and I may refuse to sign it without affecting my child’s health care.

b. I have the right to request a copy of this form after I sign it as well as inspect or copy any information to be used and/or disclosed under this authorization (if allowed by state and federal law. See 45 CFR § 164.524
c. I may revoke this authorization at any time by notifying _________ in writing. However, it will not affect any actions taken before this revocation was received or actions taken based on the previously shared information*
d. Federal privacy rules for protected health information apply only to health plans, health care clearinghouses or health care providers. If I authorize disclosure of medical information to other agencies or individuals the disclosed information may no longer be protected by federal privacy regulations.

e. Federal privacy rules for education information apply only to schools and EI/ECSE programs. If I authorize disclosure of educational information to other agencies or individuals the disclosed information may no longer be protected by federal privacy regulations.

6. than the expressed reasons stated above is prohibited. This consent is subject to revocation at any time, except to the extent that action has been taken based on information that has already been disclosed.

I consent to the use/disclosure of the above information. I understand that the use of this information for any reasons other
Signature

Clear
Relationship to Student*
Authorization Expires on*

MonthDayYear
Date
Todays Date

MonthDayYear
Date
Purpose of form:

Authorization to Use and/or Disclose Educational and Protected Health Information
- This form was created so that educational agencies could request information from health entities that require HIPAA-compliant release forms. (HIPAA: Health Insurance Portability and Accountability Act)
- This form is used when there is a need to obtain consent from a parent, legal guardian, or student/child to authorize the named agency to:
  - Send/disclose protected health information and/or educational information; and/or
  - Receive/use protected health information and/or educational information
Directions for completing the form:

Box 1. Required.
- Enter the student/child’s full legal name including middle name;
- Enter other names used by the child including nicknames;
- Enter child’s date of birth;
- Enter the name and address of the health care provider who will send or receive requested protected health and/or educational information;
- Enter the name and address of the school district or EI/ECSE program sending or receiving the requested protected health and/or educational information; and
- Check all appropriate boxes that apply indicating which provider is authorized to send and which provider is authorized to receive protected health and/or educational information.
Box 2. Required.
- Mark all the boxes that apply regarding which specific medical and/or educational records are being requested. For a record that is not represented in the list, check the “other” box and specify a different type of purpose.
Box 3. Required.
- Mark all the boxes that apply regarding how the requested protected health and/or educational information will be used. For a record not represented in the list, check the “other” box and specify a different type of record.
Box 4.
- Required only if any of the four types of records indicated are requested. This box should be left blank if none of these four types of records are requested.
- The four types of records indicated require an additional level of protection. To request any record in Box #4, the specific type of record must be listed in the spaces provided and the parent, legal guardian or student/child must initial the space before each type of record requested. For example, for mental health information, a program might indicate “psychologist’s assessment” and then the parent, guardian, or student/ child would initial the space at the beginning of the mental health information line.
Box 5. Required.
- This box contains information relating to the parent’s, guardian’s, or child’s rights in giving authorization including the right to refuse to sign, the right to request a copy after signing, the right to inspect the information to be used, and/or disclosed, and the right to revoke the authorization. Information is given that clarifies that when requested information is sent, the laws that protect that information may no longer apply since the receiving agency may not be bound by the same laws as the sending agency.
- In item c., identify who will receive the potential revocation. The statement clarifies that if an action has already been taken, for example, protected health information has already been sent, then the revocation for that specific information is not valid. However, the agency may voluntarily return the information received after the revocation has been signed and submitted.
Box 6. Required.
- Parent, legal guardian, or student/child must sign for the authorization to be valid. If parent or guardian, the relationship to the child must be indicated. The date of the signature must be entered.
- The authorization is only valid for the purposes checked or stated in the form.
Box 7. Required
- The month, day, and year that this authorization will expire must be included in the space provided. The date must not go beyond one year past the date of the signature.
Additional Directions
- Place a copy of this form into the student/child’s file.
- HIPAA requires that the school district/EI/ECSE program give a copy of the authorization form to individuals who sign it and request a copy. However, it is recommended practice that the school district/program automatically give the parent, guardian, or student/child a copy of the form after they have signed it, whether or not they request it, so they will have a record of the authorization.
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