Consent for Release of Information

I (State your name below), hereby authorize (State name of the Authorized Person below) to release information from my health/school record, and communicate with, South Royalton Health Center, with NO LIMITATIONS placed on the history of illness or diagnostic and therapeutic information, including any treatment for alcohol or drug abuse, psychiatric impairments, HIV test results/findings or School Records.

Name:

Authorized Person's Name:

I (State your name below), hereby authorize (State name of the Authorized Person below) to release ONLY THE FOLLOWING information from my health/school record, and to communicate with, South Royalton Health Center

Name:

Authorized Person's Name:

Specific Information to be Released:

Admission/Discharge Summary

Operative Report

Lab Reports

Other

IEP/504

Transcripts

Testing results used to determine developmental or academic services at school

Future communication about those checked

I (State your name below), hereby authorize South Royalton Health Center to release information from my health record to (State name of the Authorized Person Below) with no limitations placed on the history of illness or diagnostic and therapeutic information, including any treatment for alcohol or drug abuse, psychiatric impairments or HIV test results/findings.

Information covering inpatient outpatient/school services from (State Dates Below)

Name:

Authorized Person's Name:

Start Date:

To:

Patient Name:

Date of Birth:

Address:

City:

State:

Zip:

Reason for Release:

I understand that this consent can be revoked at any time. This authorization will be valid for one year unless otherwise specified.

By typing your name below, you are signing this form electronically. You agree your electronic signature is the legal equivalent of your manual signature on this application.

Signature of Patient/Guardian:

Date:

Relationship and/or authority if signed by person other than patient:

Signature of Witness:

Date:

We thank you for your cooperation and time in helping us provide optimal care for your child.

Your information will be encrypted.