I give permission for my child's school to share information with and discuss my child's health and school performance with my child's health care team as needed and as permitted by law.

• I understand that allowing my child's school to share information with my child's health care team will allow them to coordinate my child's care, provide outreach services if necessary, and keep my child healthy, safe, and engaged in school.
  
  
• I understand that, even with this consent, only those individuals at my child's health care office and school who must have access to information about my child to provide necessary services will be permitted to participate in discussions or data sharing regarding my child.
  
  
• I understand that, whenever possible, my school will include me in discussions about my child.
  
  
• I understand that I am entitled to receive a copy of any disclosed records.
  
  
• I understand that these individuals may further use records provided by my child's school or healthcare provider for contacting me and/or verifying information for student health related purposes.

I understand that my consent to allow sharing the above information is voluntary and that it is not required for my child to enroll in school or to receive care at my child's doctor. This consent will remain in effect for as long as my child is enrolled in this school district. I understand that I may revoke this consent at any time by submitting a note or letter in writing to the school administration office.

I give permission for my child's health care team to share information with and discuss my child's health and school performance with my child's school as needed and as permitted by law.

• I understand that allowing my child's health care team to share information with my child's school will allow them to coordinate my child's care, provide outreach services if necessary, and keep my child healthy, safe and engaged in school.

• I understand that, even with this consent, only those individuals at my child’s health care office and school who must have access to information about my child to provide necessary services will be permitted to participate in discussions or data sharing regarding my child.

• I understand that, whenever possible, my child’s health care provider will include me in discussions about my child.

• I understand that I am entitled to receive a copy of any disclosed records.

• I understand that these individuals may further use records provided by my child’s healthcare provider or school for contacting me and/or verifying information for student health related purposes.

I understand that my consent to allow sharing the above information is voluntary and that it is not required for my child to enroll in school or to receive care at my child's doctor. This consent will remain in effect for as long as my child is enrolled in this school district I understand that I may revoke this consent at any time by
submitting a note or letter in writing to my child's health care office.

Why are my child's school and health care provider requesting my permission to communicate and share
information?

• Your child's school and health care providers want to provide your child and family with the best possible care, including to support your child's health, wellbeing, and school performance.
• We are seeking your consent so that critical members of your child's care team can share important information about your child's health and/or school experience and to coordinate care for your child.
• This consent is necessary under two key privacy laws to protect your child's information, including the Family Educational Rights and Privacy Act (FERPA) and the Health Insurance Portability and Accountability Act (HIPAA) Privacy Rule.
• Families, including guardians and students who are developmentally able to participate in decision- making, are considered to be the center of discussions around interprofessional information sharing. The school and health care team should discuss the family's wishes at the time the consent is given and should continue to include (or notify) the family when information sharing occurs. That means guardians are given the right to decide:
  • If information-sharing can occur at all;
  • Who can be involved in this information-sharing;
  • What types of information can be shared or discussed (health updates, learning or behavior updates, school accommodations, number of school absences, etc.);
  • When the agreement ends.

• The Family Educational Rights and Privacy Act (FERPA) is a federal law that protects the privacy of student education records. Generally, schools must have written permission from the parent/guardian, or student if over 18 years of age, to release information from a student's education record to a party outside of the school.
• Schools may share information about a student with members of the school team with a need to know to provide appropriate care for the child.

• The Health Insurance Portability and Accountability Act (HIPAA) is a federal law that protects the privacy of protected health information. This law requires organizations ("covered entities") to have written permission to share certain protected health information.

• This form only allows for the sharing of limited information between your child's school and health care provider necessary to coordinate care and support your child's health, wellbeing, and school performance.
• This form does not represent consent to provide medical services for your child.
• This form does not limit the parent's ability to be notified of communications and to be aware of what information is shared.