Authorization for Disclosure of Information
Following Health Insurance Portability and Accountability Act (HIPAA) rules, School Based Health Center staff members will use and share
my Personal Health Information (HPI) for: 1) treatment of my child’s health condition and maintaining the continuity of my child’s care, 2)
payment for health services provided to my child, and 3) routine health care operations including quality improvement, accreditation,
educational purposes, or other disclosures as required by law. I understand that The Notice of Privacy Practices document is available to me
at the location(s) my child receives his/her health care services and on the Tri-Area Community Health (TACH) website.
In order for health center staff members to provide services, I authorize the school to release school records on a “need to know basis” to
the School Based Health Center staff members, and also for the School Based Health Center staff members to release medical records to
the school, the health department, and my health care provider as needed to assist in the treatment and/or continuity of care for my child.
These records may include, but is not limited to the following; immunizations records, class schedules, parental/guardian contact, address,
phone number, medical and behavioral health conditions, health screenings, medications, health care plans, or attendance information.
The medical and mental health providers from the School Based Health Center may participate in student success or attendance teams if
needed. I also authorize other health care providers for the student listed above to release information to the School Based Health Center
staff members as needed.
I understand that if my child requires the School Based Health Services, reasonable attempts will be made to contact me and if I cannot be
reached, I give consent for my child to be seen by the providers at the clinic.
I hereby authorize the School Based Health Center to provide the services as indicated above. I authorize TACH to file my insurance for
services rendered. I request that payment be made directly to TACH. I understand that I am responsible for all charges incurred regardless
of my insurance status or lack thereof. Slide fee applications are available at www.triareahealth.org.
By signing this consent, I confirm I am the parent/legal guardian of the above listed student and am authorized to give
this consent. This consent will be in effect for one year from this date.