CCJS - Release of Information Authorization

Release of Education and Medical Records

Clinton County Joint Services
Students Name*
Birthdate*

MonthDayYear
Date
Address*
Phone Number*
Present School Attending*
Program Placement*
This Release of Educational and Medical Records is used to obtain records from other schools, educational providers, medical providers or agencies. The parent or guardian should check the appropriate boxes, sign, date and return the form to begin the release.
STEP 1 - CHECK REASON(S) FOR RELEASE:*

Assist with the implementation of the education programFacilitate communication with persons involved with the studentProvide previous educational recordsObtain Medical or Mental Health recordsOther
The following will be released and this release is valid until no later than one year from the date of the consent or it will end on (indicate a specific date)
Date*

MonthDayYear
Date
STEP 2 - RECORDS TO BE RELEASED:*

All records and information which exist, either verbal or written, may be released.Only these specific records may be released, either verbal or written : (check all that apply)Psychological Reports, Case Conference Summaries, and Individual Educational PlanEducational data such as teacher reports, conference reports, instructional objectives, and Individual Education PlanMedical and health information and records (which include but are not limited to school nurse records)Social and emotional information and records (which include but are not limited to counselor/social work reports, Psychiatric evaluations,Hospital admission/discharge or therapy notes/reports, and discharge summary)Cumulative school records (which include but are not limited to scholastic records or grades, standardized test results, attendance records,and school nurse records)Other school records (List specific information to be released)
STEP 3 - RELEASE RECORDS TO WHOM: This individual's records may be released or obtained by the following: FROM: Person/Organization TO: Person/Organization AddressAddress
FROM Person/Organization*
Address*

Address

Street Address Line 2

CityStateZipState / Province

Postal / Zip Code
Telephone/Fax*
TO: Person/Organization*
Address*

Address

Street Address Line 2

CityStateZipState / Province

Postal / Zip Code
Telephone/Fax*
STEP 4 - PARENT/GUARDIAN APPROVAL: Check, sign and date the Release.

I, parent/guardian of the individual indicated above, authorize Clinton County Joint Services to release/disclose/obtain/exchange confidential records and information to or from the person(s) or organization designated on this Release. I understand that I may request a copy if any records received or released and have the right to challenge the contents of any school records, as provided by the Family Educational Rights and Privacy Act of 1974. I understand this disclosure of confidential information pursuant to this release can no longer assure how the recipient will use the records.

This Release is subject to revocation at any time except to the extent where records have already been disclosed. The release is valid for one year from the date signed or until the date indicated in Step 2.
Check your choice below*

I agree to the above indicated release of information and records.I do not give my permission for the release of any information to or from the Clinton County Joint Services Cooperative.
NOTICE TO RECIPIENT OF RECORDS: This information is being disclosed to you from records protected by confidentiality rules. The federal and state rules prohibit you from making any further disclosure of this information unless written consent is obtained from the parent/guardian/student.
Signature*

Clear
Date*

MonthDayYear
Date
Should be Empty:

Release of Education and Medical Records