AUTHORIZATION FOR RELEASE/EXCHANGE OF CONFIDENTIAL INFORMATION (WCPSS Students)

AUTHORIZATION FOR RELEASE/EXCHANGE OF CONFIDENTIAL INFORMATION

(Wake County Public School Students Only)
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.
Full name of student (patient):*
Student's Date of birth:*

MonthDayYear
Date
Student ID #:
Outside Provider:
Name of Outside Provider:*
Agency:
Telephone Number:*

Area CodePhone Number
Fax Number:

Area CodePhone Number
Email
example@example.com
The outside provider listed above may provide information to White Plains Children's Center and/or WCPSS *
The outside provider listed above may receive information from White Plains Children's Center and/or WCPSS*
School:
School Name*
Individual's Name*
Position/Title:*
Telephone Number:

Area CodePhone Number
Fax Number:

Area CodePhone Number
E mail:
example@example.com
May the person listed above provide protected health information to the outside provider?*

YESNO
May the person listed above provide educational records and/or personally identifiable information to the outside provider?*

YESNO
Information to be provided/exchanged
Information to be provided/exchanged (check all that apply):*

Medical recordsGradesImmunization recordsTreatment recordsAttendanceDisciplinary recordsDiagnostic recordsSpecial education fileOther
This information is provided for the following purpose:*
This authorization shall expire on:*

MonthDayYear
Date
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*
Signature of parent/legal guardian/student (if 18 or over)*

Clear
Date*

MonthDayYear
Date
Should be Empty:

AUTHORIZATION FOR RELEASE/EXCHANGE OF CONFIDENTIAL INFORMATION

Outside Provider:

School: