Authorization for Access, Release and Use Educational Information

Date:

This release will expire one year from today's date.

Client Name:

First NameLast Name

Date of Birth:

Date

Contact Email Address:

example@example.com

The person named above is or has been a client of A Chance to Grow, Inc. (hereafter referred to as ACTG). ACTG is required to keep personal information, identifying information, and records confidential. By signing below, clients allow ACTG to access, send, and/or use information from certain individuals or agencies named.

Educational Release:

I hereby authorize ACTG to:

Request educational information fromSend educational information toDiscuss educational information with (provide school details below):I do not authorize ACTG to request, send, or share my educational information at this time.

School:

Case Manager and/or Teacher:

Address:

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code

Phone Number:

Fax Number:

Scope of information to be released:

All information regarding assessment, diagnosis, and treatmentOther (please specify below)

Other information to be released:

Please initial the following:

Initial   I understand that this authorization is effective for the above requested and authorized educational information only.
Initial   I understand that I have the right to inspect the information I am authorizing to be re-released. This and other specific rights regarding the handling of your health information are outlined in our privacy practices document.
Initial   I understand I do not have to allow A Chance To Grow, Inc. to share my information and that signing a release form is completely voluntary. My refusal to sign this authorization will not affect my ability to obtain treatment except to the extent that the information being requested may assist ACTG in determining appropriate treatment.
Initial   I understand that if I would like A Chance To Grow, Inc. to release information about in the future, I will need to sign another written, time-limited release. This release is limited to the information contained in this document.
Initial   I understand that my information may be shared in person, by phone, fax, mail, or email. I understand that email is not confidential and can be intercepted and read by other people. Releasing information about me could give another agency or person information about my location and would confirm that I have been receiving services from ACTG.
Initial   I understand that I may withdraw my consent to this release at any time in writing. ACTG may not be able to control what happens to my information once it has been released to the above person or agency, and that the agency or person getting my information may be required by law or practice to share with others.
Initial   I understand that records created by and available from other providers, hospitals, or other care facilities must be obtained directly from those other providers or facilities.

Authorization:

Name:

First NameLast Name

Client or Guardian Signature:

Date:

If not signed by client, indicate relationship of authorizing representative to client:

Authorization for Access, Release and Use of Educational Information