HIPAA Authorization for School Health Records
Student Information
Student Name
Date of Birth
School Name
Parent/Guardian Information
Name
Relationship to Student
Health Provider Releasing Records
Provider/Facility Name
Provider Address
Provider Phone
Information to be Released
Purpose of Disclosure
Recipient
Individual/Organization Receiving the Information
Recipient Address
Authorization Details
This authorization expires on
Other Conditions (if any)
Signature
Signature of Parent/Guardian
Date