NSK Release Assent

North Star Kids Release of Information Assent Form

(Permission to Share Information)
You are signing this form because you are between the ages of 12 and 17 and have the right to decide whether your provider at North Star Kids can share information about your treatment with others.
Your parent/guardian has authorized the release of your health information to:*
Please enter the name exactly as it appears on the Release of Information form signed by your parent/guardian. If you’re unsure, refer to the message you received or ask your provider.
My Decision About Sharing Information:*

I agree to allow my provider to share information with the above entity.I do NOT agree to allow my provider to share information with the above entity.
What Information Can Be Shared?

My diagnosisMy progress in treatmentTreatment recommendationsSchool-related informationOther
Patient Name:*
Patient Signature:*

Clear
Date*

MonthDayYear
Date
Should be Empty:

North Star Kids Release of Information Assent Form