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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