Name __________________________________Date of Birth __________________________________________

Address ______________________________________________________________________________________

Social Security/Student Number ___________________________

I authorize the Lincoln Park Public Schools to disclose/request (circle one) information in my records to/from:

Name of Individual of Facility

Address of Individual or FacilityTelephoneFax

Check Specific Information to be Released/Requested:

__ Psychological Testing__ Intake and Discharge Summary
__ Academic Testing__ Psychiatric Evaluations
__ Speech and Language TestingX   Medical Test Reports: Diagnosis, Prognosis, Corrected Visual Acuity,
__ Social Work Evaluation    and Visual Field Test Results
__ IEP, MET, Evaluation Review__ Other _____________________

The Purpose and Need for Such Disclosure/Request: ___________________________________________________________


I understand that my medical records may contain information regarding testing, drug, and/or alcohol diagnosis and treatment, a communicable or venereal disease which may include, but is not limited to, diseases such as hepatitis, syphilis, gonorrhea, or the human immunodeficiency virus, also known as acquired immune deficiency (AIDS) and/or tuberculosis.  I understand that such information is confidential and is protected by federal law.   I understand that the provision of health care treatment to me cannot be conditioned upon my agreement to sign an authorization for the disclosure or use of my health information for purposes other than for treatment, payment, and healthcare operations. I understand that the potential exists for heath information that is released with my authorization to be re-disclosed by the recipient, and to be no longer protected by the Federal HIPAA law.  I understand that I have the right to revoke this authorization at any time by giving written notice to Privacy Officer, except to the extent that action has already been taken  in reliance on it.  This authorization will expire 60 days following signature unless another date or condition is specified.


Parent/Guardian                                         RealtionshipDate


Special Services
2800 Lafayette Blvd., Lincoln Park, MI  48146
  Phone:  313-389-0210Fax: 313-389-0752

*Drug and alcohol records are protected by Federal confidentiality ruling (42 CFR part 2) and require written consent to disclose this information unless otherwise permitted by 42 CFR part 2.  Further disclosure is prohibited without written consent by the person to whom the information pertains unless otherwise permitted by the law.  The Federal rules restrict any use of the information to criminally investigate or prosecute any alcohol or drug abuse patient.