Authorization for Release of Information

Consumer's Name

Consumer's DOB

I authorize Northeast Deaf and Hard of Hearing Services, Inc. (NDHHS) to request and/or share information and records pertaining to my child with:

Name of agency/person

Title (if known):

Phone number:

Address

City

State

Zip

I understand that this Authorization permits NDHHS to:

Communicate with the agency/person listed above regarding coordination of early intervention/special education and related services for my child
Request from the agency/person listed above: reports, evaluations, progress notes and recommendations
Share with the agency/person listed above any information that is maintained in my child's NDHHS file, whether generated by persons employed by or contracted with NDHHS

I authorize NDHHS to request and/or share information and records pertaining to my child EXCEPT as follows:

I understand that this information obtained will be treated in a confidential manner by NDHHS under the provisions of the Family Education Rights and Privacy Act (FERPA). FERPA prohibits disclosure of personally identifiable information without consent except in limited circumstances. Please note that if the request is for health or medical information, the medical information received by NDHHS is protected under FERPA privacy standards and not the Health Insurance Portability and Accountability Act (HIPAA

This authorization is effective for a period of no longer than twelve (12) months. I understand that my consent for the release of records is voluntary and can withdraw my consent at any time in writing. Should I withdraw my consent, it does not apply to information that has already been provided under the prior consent for release.

Parent/Guardian signature/Student*

Clear

Date

*The parties agree that the electronic signature of a party to this Agreement shall be as valid as an original signature of such party and shall be effective to bind such party to this Agreement.