PARENT PERMISSION TO OBTAIN AND RELEASE INFORMATION (TWO WAY COMMUNICATION)

This form is for outside agencies to communicate directly with schools regarding a child's educational information. Examples include: medical or therapy or counseling personnel.

I, the undersigned, hereby request and authorize:
School/Agency
Choose your child's school:

Choose your child's school: Altoona Elementary Altoona Intermediate Altoona Middle School Altoona High School 4K
Address Address
Street Address Address Line 2 City State / Province / Region Postal / Zip Code Country
Contact Contact First Last
To release to, and/or obtain from:
School/Agency/Person:
Address Address
Street Address Address Line 2 City State / Province / Region Postal / Zip Code Country
Contact Contact First Last
The information which I have indicated below:
Name of Student Name of Student First Last
Date of Birth Date of Birth / MM / DD YYYY
Official student academic/administrative records (identifying information, grade level completed, grades, class rank, attendance records, and group aptitude and achievement assessment results) Medical and / or related health records. (Fill type of provider below) Medical history/diagnostics/therapeutic informatio (Select date range and additoinal info below) Specific information (i.e. x-rays films, photographs) or verbal exchange with (x-rays, reports) Medical information limited to (Fill in information below) Psychological evaluations or social work reports Appropriate agency reports Exchange / release of the IEP documents Attendance, participation, development and implementation of IEP Other (specify) Other (specify)

Certain items, when checked, will give you an opportunity to input additional information.
Type of Provider for Medical and/or Related Health Records
Medical History/Diagnostics/Therapeutic Information Date From: Medical History/Diagnostics/Therapeutic Information Date From: / MM / DD YYYY
Medical History/Diagnostics/Therapeutic Information Date To: Medical History/Diagnostics/Therapeutic Information Date To: / MM / DD YYYY
Medical History/Diagnostics/Therapeutic Information (Optional)

Medical History/Diagnostics/Therapeutic Information (Optional) Mental Health HIV Developmental/Learning Disablility Drug/Alcohol Abuse
Medical Information Limited to
Purpose of Disclosure
YOUR RIGHTS WITH RESPECT TO THIS AUTHORIZATION

Right to Inspect or Copy the Health Information to be used or disclosed - - I understand that I have the right to inspect or copy the health information that I
have authorized to be used or disclosed by this authorization form. I may arrange to inspect my health information or obtain copies of my health information by
contacting the health information department or school.

Right to Receive Copy of this Authorization - - I understand that if I agree to sign this authorization, which I am not required to do, I must be provided with a
signed copy of the form.

Right to Refuse to Sign this Authorization - - I understand that I am under no obligation to sign this form and that the person(s) and/or organization(s) listed
above whom I am authorizing to use and/or disclose my information may not condition treatment, payment, enrollment in a health plan or eligibility for health
care benefits on my decision to sign this authorization.

Right to Withdraw this Authorization - - I understand that written notification is necessary to cancel this authorization. To obtain information on how to
withdraw my authorization or to receive a copy of my withdrawal, I may contact the health information department or school. I am aware that my withdrawal will
not be effective as to uses and/or disclosures of my health information that the person(s) and/or organization(s) listed above have already made in reference to
this authorization.

I understand that I may revoke this authorization at any time by submitting written notice of the withdrawal of my consent and that the written revocation must be
given to the agency/organization I authorized to release information. I recognize that health records, once received by the school district, may not be protected
by the HIPPA Privacy Act and my become education records protected by the Family Educational Rights and Privacy Act (FERPA) with additional protection
afforded by Wisconsin Statues 118.25(2m)(a)(b) and 146.83. I also understand that if I refuse to sign, such refusal will not interfere with my own ability to obtain
health care.
**This permission is valid for one year from the date signed. A copy of this form is as effective as the original.
I give my consent to obtain and release information as described above regarding: (Type name below) I do not give my consent to obtain and release information as described above regarding: (Type name below)
Student Name Student Name First Last
Signature of Parent or Legal Guardian

Draw or Type

I understand this is a legal representation of my signature. Clear

Full Name

I understand this is a legal representation of my signature.
Date Signed Date Signed / MM / DD YYYY
Email

Copy of this form will be sent to this email address.
The school district does not discriminate on the basis of race, sex, age, religion, disability, or national origin.

PARENT PERMISSION TO OBTAIN AND RELEASE INFORMATION (TWO WAY COMMUNICATION)

PARENT PERMISSION TO OBTAIN AND RELEASE INFORMATION (TWO WAY COMMUNICATION)

I, the undersigned, hereby request and authorize:

To release to, and/or obtain from:

The information which I have indicated below:

YOUR RIGHTS WITH RESPECT TO THIS AUTHORIZATION

**This permission is valid for one year from the date signed. A copy of this form is as effective as the original.