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.
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*