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  • Permission to Share Health Information

  • This form gives permission to share information with and get information from people who help take care of you/your student, while keeping the information private and safe.

  • Student/Client Information:

  • Today's Date:
     - -
    2 digit month, 2 digit day, 4 digit year
  • Student's Date of Birth:
     - -
    2 digit month, 2 digit day, 4 digit year

  • Person or Place We Can Share Information With:

  • I give permission to share (communicate, send, or receive) my health information with:

  • What can be shared:

  • Reason for Sharing:

  • How Long This Permission Lasts:

  • This permission lasts until (choose one:
  • How Long This Permission Lasts:

  • CONCORD SCHOOL WELLNESS PROGRAM

  • My Rights

  • I can say no to sharing my information.

    I can change my mind at any time by telling the SWP office in writing. 

    Saying no will not stop me from getting care or change the care I receive. 

    If shared, the person/organization who receives it may share it again unless told not to. 

  • Signatures

  • Today's Date:
     - -
    2 digit month, 2 digit day, 4 digit year
  • Today's Date:*
     - -
    2 digit month, 2 digit day, 4 digit year

  • Contact

  • If you have questions about this form or your health information, or you would like to remove permission to share with others, please contact:
    Jackson County Health Department - School Wellness Program
    Phone: (517) 817-4086
    Email: concordswp@mijackson.org
  • If you would like to file a complaint, please contact:
    Holly Flickinger - Deputy Health Officer CHEP
    517-768-1638
    hflickinger@mijackson.org
  • Should be Empty: