WPCC AUTHORIZATION FOR RELEASE/EXCHANGE OF CONFIDENTIAL INFORMATION

AUTHORIZATION FOR RELEASE/EXCHANGE OF CONFIDENTIAL INFORMATION
I, (name of parent/guardian)*, hereby authorize the provider listed below to disclose certain protected health/education information of the student named below to officials of the White Plains Children’s Center for the purpose indicated below. If indicated, I also give permission to officials of the White Plains Children’s Center to disclose confidential education records to the provider indicated below.
Student's Full Name: *
Student's Date of Birth: *

Month Day Year
Date
Outside Provider:
Name: *
Agency:
Telephone Number: *
Fax Number:
Email *
example@example.com
Check all that apply: *

Outside provider may provide information to WPCC Outside provider may receive information from WPCC
White Plains Children’s Center:
Name: *
Position/Title: *
Telephone Number:
Fax Number:
E mail: *
example@example.com
May provide protected health information to the outside provider? *

Yes No
May provide educational records and/or personally identifiable information to the outside provider? *

Yes No
Information to be provided/exchanged (check all that apply): *

Medical records Grades Immunization records Treatment records Attendance Disciplinary records Diagnostic records Special education file Verbal Communication
This information is provided for the following purpose: *
This authorization shall expire on: *

Month Day Year
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 this form was completed prior to my signing my name below. Initials*
Signature of parent/legal guardian/student (if 18 or over) *

Clear
Date *

Month Day Year
Date
Should be Empty:

AUTHORIZATION FOR RELEASE/EXCHANGE OF CONFIDENTIAL INFORMATION

Outside Provider:

White Plains Children’s Center: