[School-nurse] HIPAA form

[Paula Smith (ADE)]

Thanks. Here is another one sent from Kathleen Bowen at Pyron. 

 

Release of Student Medical Information

 

 

The purpose of this form is to provide acknowledgement of the parental /
guardians authorization to the school caregivers to share information
with pertinent school staff that the parent and/or nurse deem necessary
for the care of ____________________________  a student at
____________________________ school.  

 

I, ____________________________, the legal parent / guardian of the
above named student give my permission for the designated care givers of
my child to share medical care information with pertinent school staff.
This information shall be disclosed on a need to know basis only
pertaining to the care of my child at school, field trips, activities,
and other designated school functions.

Pertinent staff includes but is not limited to the following: 

 

Teacher (s) ___                 School Secretaries ___
Custodians ___

Principal ___                       Cafeteria Manager ___
Transportation ___

Other ___________________________________________________

 

Signature: _________________________________

 

Printed Name: ______________________________

 

Date: ___/___/___

 

Nurse: __________________________________

 

Other: ___________________________________ 

 

 

 

++++++++++++++++++++++++++++++++++++++++++++++++++++++++++++++++++++++++
+++++++++++++++++++++++

 

 

Verbal Acknowledgement of Release of Student Medical Information Consent
for release of student medical information was received on  __/__/__ by
phone / in person from  _________________ (parent / guardian) was
received by _________

Healthy children are healthy learners!

 

Paula Smith, MNSc., RNP

State School Nurse Consultant

Arkansas Department of Education

Coordinated School Health

2020 West 3rd St., Suite 320

Little Rock, AR 72205

office (501) 683-3600

fax (501) 683-3611

paula.smith at arkansas.gov

 

Visit our website:

http://www.arkansascsh.org

 

 

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