Download Authorization for Release of Health Data

AUTHORIZATION TO USE OR DISCLOSE HEALTH INFORMATION
Name
Address
City
DOB
____________________________________________________
____________________________________________________
________________State______Zip _______________________
________________
Social Security Number ____________
I hereby authorize the disclosure of protected health related information regarding the above named child
between the Danville Public Schools and:
Attention:
_________________________________
_________________________________
_________________________________
The specific information to be disclosed is:
Department of Exceptional Children
Danville Public Schools
P.O. Box 9600
Danville, Virginia 24543
434 799 6400 (phone)
434 797 8985 (fax)
________________________________________________________________________
________________________________________________________________________
Dates requested: From: _______________________To: _________________________
The purpose of this disclosure is: To assist with appropriate educational planning and care
I acknowledge that the information disclosed pursuant to this authorization may be subject to re-disclosure by the recipient
and no longer protected by Federal Law.
I acknowledge that I have the right to revoke this authorization by written notice to: Sharon Eldridge Bohannon,
Department of Exceptional Children, Danville Public Schools. I understand that actions taken in reliance on this
authorization cannot be reversed, and my revocation will not affect those actions.
This authorization expires on _____________
**If no date is specified, this authorization will expire six months from the date of signature**
I understand that the information in my medical records may include information relating to treatment of drug or alcohol
abuse, mental health, sexually transmitted disease, acquired immunodeficiency syndrome (AIDS), AIDS related complex
(ARC) and /or human immunodeficiency virus (HIV).
_________________________________
Signature of Parent or Patient Representative
____________________
Date of Signature
*If signed by a personal representative, a description of the representative’s authority to act is as follows:
Parent
Legal Guardian