HIPAA Consent
If you have been asked to complete this form, you have previously submitted paperwork missing a piece of information required for treatment at Giles High School Center of Community Health Center of the New River Valley. This form was created to allow you to submit missing information with the least inconvenience possible.
Student Name
First Name
Middle Name
Last Name
Student Date of Birth
HIPAA Release of information
List any person who we can talk to about your student's medical conditions (Protected Health Information) and their appointments. This excludes Behavioral Health and Substance Abuse conditions (Sensitive Protected Health Information): A separate release of information will need to be signed to discuss these with other individuals.
Name
Phone
Relationship
Name
Phone
Relationship
Name
Phone
Relationship
Name
Phone
Relationship
ParentSignature
By signing, I agree that I have provided true answers to the best of my knowledge. It is my responsibility, as the student's guardian, to contact previous provider’s offices for transfer of medical records. I have the ability to ask for a copy of my student's medical records at any time from CHCNRV. I have reviewed the Notice of Privacy Practices (HIPAA).
Date
-
Month
-
Day
Year
Date
Submit
Should be Empty: