CONSENT FOR INFORMATION DISCLOSURE
CUSTER SCHOOL DISTRICT 16-1
Special Education Department
527 Montgomery Street
Telephone: 605-673-2171 Custer, SD 57730 Fax: 605-673-3079
Student: ______
Birthdate: ______
I, ______, authorize Custer School District to: (check either or both).
(Print Name of Student/Parent/Guardian) (Person/Organization, Address, Phone/Fax)
[ ] receive information from, [ ] disclose information to: ______
______
______
______
Disclosed Information Limited To: Purpose for Disclosure:
1) Educational Assessment including: ability,
achievement, adaptive behavior c Establish History/Diagnosis/Individual Education Plan c
2) IEP c Coordinate Services c
3) School attendance records c Court Testimony c 4) Psychological Evaluation c Referral for Services c
5) Psychiatric Evaluation c Evaluation c
6) Diagnosis Information c
7) Medical Information (Including Medication) c Other: ______c
8) Summary of Contacts and Treatments c
9) Discharge Summary c Other: ______c
10) Client Attendance at Appointments c
Other: ______c
Other: ______c
FORM IN WHICH INFORMATION IS TO BE DISCLOSED:
c Written c Verbal c Fax c E-Mail c Other ______
Prohibition on Re-disclosure: Information authorized by this consent has been disclosed from records whose confidentiality is protected by Federal Regulations (42CFR Part 2). Federal regulations prohibit disclosure of this information except with specific written consent of the person to whom it pertains, unless otherwise provided for in the regulations. A general authorization for the release of medical or other information if held by another party is NOT sufficient. The Federal regulations (42CFR Part 2) restrict any use of the information to criminally investigate or prosecute an alcohol or drug abuse history patient.
I understand that my records are protected under State and/or Federal regulations and cannot be disclosed without my written consent unless otherwise provided for in State and/or Federal regulations. I also understand that I may revoke this consent at any time except to the extent that action based on this consent has been taken. This consent will expire on the date or event specified. If not specified, this consent will expire 1 year from the termination of services.
Specification of any special date, event, or condition upon which this consent expires: ______
Date
______
Parent / Guardian Date Parent/ Guardian Date
______Witness
THIS FORM WILL BECOME PART OF THE STUDENT’S EDUCATIONAL RECORD AND SHALL BE VALID FOR ONE YEAR
Information was released: ______Faxed by: ______
Date: ______