• AUTHORIZATION FOR RELEASE/EXCHANGE OF CONFIDENTIAL INFORMATION

    (Wake County Public School Students Only)
  • I,   *   *   (name of parent/guardian/student if 18 or over), hereby authorize the provider listed below to disclose certain protected health/education information of the student named below to officials of the Wake County Public School System or White Plains Children's Center for the purpose indicated below. If indicated, I also give permission to officials of the Wake County Public School System and/or White Plains Children's Center to disclose confidential education records to the provider indicated below.

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  • Outside Provider:

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  • School:

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  • Information to be provided/exchanged


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  • Please read and initial the following statements:

  • I acknowledge that I may revoke this authorization by providing notice, in writing, to either of the persons/organizations named above at the address indicated above. I further acknowledge that such notice does not apply to information disclosed prior to either party receiving notice of my request to revoke this authorization.   *   

  • I acknowledge that I may refuse to sign this authorization and that my refusal will not affect my ability or inability to obtain treatment, payment, enrollment, or eligibility for benefits from the outside provider.   *   

  • I acknowledge that the Wake County Public School System is subject to confidentiality rules under federal and state law that differ from those of the agency providing this information.   *   

  • I acknowledge that this form was completed prior to my signing my name below.   *   

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