I, First Name* Last Name* (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.
Information to be provided/exchanged
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. Initials*
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. Initials*
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. Initials*
I acknowledge that this form was completed prior to my signing my name below. Initials*