Please Select the Student's School* Kingsland Public Schools Pine Island Public Schools Rochester Public Schools Stewartville Public Schools Student's Name* First Last Date of Birth* MM slash DD slash YYYY Parent/Guardian Name* First Last Parent/Guardian Address Street Address City State / Province / Region ZIP / Postal Code Consent* I hereby authorize Independent School District 2137, Kingsland Public Schools and its staff as follows:To release information to and obtain information from Zumbro Valley Health Center. School records may be examined by guardian(s), or student if age 18 or older. The information to be released: • All school records and educational data • All health records and related data • Psychological reports and related data • Special Education and all related records and data • Teacher, Counselor, Staff Observations • Medical report (including related services) • Billing records • Chemical Abuse/Dependency data • Psychiatric report • Social Work report • SLMH Grant Funding information The purpose of this request is coordination of services and referrals. I understand that this authorization takes effect the day I sign it. It expires one more year from the date of my signature. I also understand that I may revoke this authorization at any time by providing a signed, written notice of revocation to the Director of Student Services for Kingsland Public Schools. A photocopy or facsimile of this Authorization has the same legal effect as the original. In the case of protected health or medical information, I hereby authorize the healthcare provider to discuss, disclose and otherwise release any and all medical records, medical data, and health data identified above to Kingsland Public Schools and its staff and representatives pursuant to the Health Insurance Portability and Accountability Act ("HIPAA") privacy regulations, 45C.F.R § 164.508. I understand that the healthcare provider may not condition treatment or payment on whether I execute this authorization. Health or medical information that is disclosed pursuant to this authorization may be subject to redisclosure and may no longer be protected by the privacy regulations promulgated pursuant to HIPAA. Records that are received by the School District may be protected from re-discloser under the Family Education Rights Privacy Act and the Minnesota Government Data Practices Act.Consent* I hereby authorize Independent School District 255, Pine Island Public Schools and its staff as follows:To release information to and obtain information from Zumbro Valley Health Center. School records may be examined by guardian(s), or student if age 18 or older. The information to be released: • All school records and educational data • All health records and related data • Psychological reports and related data • Special Education and all related records and data • Teacher, Counselor, Staff Observations • Medical report (including related services) • Billing records • Chemical Abuse/Dependency data • Psychiatric report • Social Work report • SLMH Grant Funding information The purpose of this request is coordination of services and referrals. I understand that this authorization takes effect the day I sign it. It expires one more year from the date of my signature. I also understand that I may revoke this authorization at any time by providing a signed, written notice of revocation to the Director of Student Services for Pine Island Public Schools. A photocopy or facsimile of this Authorization has the same legal effect as the original. In the case of protected health or medical information, I hereby authorize the healthcare provider to discuss, disclose and otherwise release any and all medical records, medical data, and health data identified above to Pine Island Public Schools and its staff and representatives pursuant to the Health Insurance Portability and Accountability Act ("HIPAA") privacy regulations, 45C.F.R § 164.508. I understand that the healthcare provider may not condition treatment or payment on whether I execute this authorization. Health or medical information that is disclosed pursuant to this authorization may be subject to redisclosure and may no longer be protected by the privacy regulations promulgated pursuant to HIPAA. Records that are received by the School District may be protected from re-discloser under the Family Education Rights Privacy Act and the Minnesota Government Data Practices Act.Consent* I hereby authorize Independent School District 535, Rochester Public Schools and its staff as follows:To release information to and obtain information from Zumbro Valley Health Center. School records may be examined by guardian(s), or student if age 18 or older. The information to be released: • All school records and educational data • All health records and related data • Psychological reports and related data • Special Education and all related records and data • Teacher, Counselor, Staff Observations • Medical report (including related services) • Billing records • Chemical Abuse/Dependency data • Psychiatric report • Social Work report • SLMH Grant Funding information The purpose of this request is coordination of services and referrals. I understand that this authorization takes effect the day I sign it. It expires one more year from the date of my signature. I also understand that I may revoke this authorization at any time by providing a signed, written notice of revocation to the Director of Student Services for Rochester Public Schools. A photocopy or facsimile of this Authorization has the same legal effect as the original. In the case of protected health or medical information, I hereby authorize the healthcare provider to discuss, disclose and otherwise release any and all medical records, medical data, and health data identified above to Rochester Public Schools and its staff and representatives pursuant to the Health Insurance Portability and Accountability Act ("HIPAA") privacy regulations, 45C.F.R § 164.508. I understand that the healthcare provider may not condition treatment or payment on whether I execute this authorization. Health or medical information that is disclosed pursuant to this authorization may be subject to redisclosure and may no longer be protected by the privacy regulations promulgated pursuant to HIPAA. Records that are received by the School District may be protected from re-discloser under the Family Education Rights Privacy Act and the Minnesota Government Data Practices Act.Consent* I hereby authorize Independent School District 534, Stewartville Public Schools and its staff as follows:To release information to and obtain information from Zumbro Valley Health Center. School records may be examined by guardian(s), or student if age 18 or older. The information to be released: • All school records and educational data • All health records and related data • Psychological reports and related data • Special Education and all related records and data • Teacher, Counselor, Staff Observations • Medical report (including related services) • Billing records • Chemical Abuse/Dependency data • Psychiatric report • Social Work report • SLMH Grant Funding information The purpose of this request is coordination of services and referrals. I understand that this authorization takes effect the day I sign it. It expires one more year from the date of my signature. I also understand that I may revoke this authorization at any time by providing a signed, written notice of revocation to the Director of Student Services for Stewartville Public Schools. A photocopy or facsimile of this Authorization has the same legal effect as the original. In the case of protected health or medical information, I hereby authorize the healthcare provider to discuss, disclose and otherwise release any and all medical records, medical data, and health data identified above to Rochester Public Schools and its staff and representatives pursuant to the Health Insurance Portability and Accountability Act ("HIPAA") privacy regulations, 45C.F.R § 164.508. I understand that the healthcare provider may not condition treatment or payment on whether I execute this authorization. Health or medical information that is disclosed pursuant to this authorization may be subject to redisclosure and may no longer be protected by the privacy regulations promulgated pursuant to HIPAA. Records that are received by the School District may be protected from re-discloser under the Family Education Rights Privacy Act and the Minnesota Government Data Practices Act.Parent/Guardian Email*
