AUTHORIZATION TO SHARE CONFIDENTIAL INFORMATION (draft)

Authorization to share confidential information

Form Title

Student Name

Date

Before requesting or sharing confidential information, CHEK ABC requires that you authorize this request by completing the following:

I/We give permission to CHEK ABC personnel as necessary to:(Required)

Release pertinent records that include IEP, Assessments, Psychology reports, Doctors Reports, report cards etc: and

Request records and pertinent information from the following individual(s) and/or organization(s)/ school:

1) Doctors reports, professional reports, referrals, assessments,
2) Student records including Report Cards, IEP, Inclusions – Professional Reports.

Sharing of relevant confidential information may be undertaken for the purpose(s) of improving educational programming, helping to provide appropriate school based planning, and obtaining community-based services for your child. I understand the reason for and nature of the confidential information to be shared.

Comments (optional)

Date Signed

Signature

By signing your signature below, you acknowledge that it will serve as your legal signature, authorizing the release of confidential information.