CONSENT FOR EXCHANGE OF INFORMATION

I hereby authorize:
(Agency) ___________________________________________________________________
(Address)___________________________________________________________________
to exchange information
about my child ___________________________ Date of Birth ______________
with (Clinician) ____________________________________________________________
(Address)___________________________________________________________________.

Please exchange the following types of information (check all that you approve):
_____ questionnaires
_____ academic records
_____ medical records
_____ mental health records
_____ developmental testing/assessments
_____ other (specify)

I understand that:

• this authorization is aimed at assisting my child's doctor in helping my child.
• this authorization is voluntary.
• my child's treatment will not change if I do not agree to this.
• the only risk is loss of confidentiality. I also understand that the computer system being used by the teacher to answer questions about my child is secure.
• my child's records are protected as confidential under Federal law.
• I may revoke this consent at any time except to the extent that action has been taken on it (e.g., already communicated).
• this consent automatically expires in one year, if my child changes doctor or if my child is no longer cared for by this agency.
• that I may copy this form and that I may request a copy of the information provided.

____________________________________________________

Parent or guardian name printed

____________________________________________________

Signature

Today's date: __ __ /___ ___ /___ ___ (Month Day Year)

____________________________________________________

Witness