PARENT/GUARDIAN PERMISSION FOR RELEASE OF CONFIDENTIAL DATA
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Email *
Type your child's full name below. *
Provide your child's date of birth. *
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Write the name of your child's school below. *
What grade is your child in?
Please check which documents/information you agree to release or allow the LEC Staff to share. *
Required
Please provide the name of the person(s) that the LEC staff can release and/or exchange information to below (e.g. child's teacher, physician, therapist, etc.). *
Type the email of the above person(s) below. *
Type the name of the office/building where they are located below. *
This authorization will automatically expire 1 year from the date signed below or the date the minor child becomes an adult under state law, unless I request an expiration date sooner than 1 year. I may choose to revoke this authorization at any time, except to the extent that action has already been taken to comply with it, by notifying the LEC in writing. Information disclosed pursuant to the authorization may be subject to re-disclosure by the recipient and is no longer protected by the HIPAA Privacy Rule. I will be provided a copy of this authorization upon fulfillment of the request. The LEC will still provide treatment and seek payment for services provided, whether or not I sign this authorization. If this consent is completed or signed electronically, the parties agree that this consent shall be fully effective and enforceable against the parties completing or signing this consent via electronic means.
By writing my name below, I agree to the above statement. *
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