Emergency Medical Form

Authorization to School for Emergency Medical Treatment for Minor

I, , of , am the of , a minor, of , who attends , located at .

I hereby give my consent, if all reasonable attempts by authorized school personnel to contact me at or at have been unsuccessful, for the following:

1. The administration of any treatment deemed necessary by or or, if the appropriate practitioner is not available, by another licensed physician or dentist; and

2. The transfer of , to or any hospital reasonably accessible.

This authorization does not cover major surgery unless the medical opinions of two other licensed physicians concurring in the necessity for such surgery are obtained prior to the performance of such surgery.

The following information is needed by any hospital or practitioner not having access to 's medical history:

Allergies:

Medication being taken:

Date of last tetanus shot:

Physical impairments:

Other pertinent facts to which physician should be alerted:

HIPAA Release Authority. My agent shall be treated as I would be with respect to my rights regarding the use and disclosure of my child’s individually identifiable health information or other medical records. This release authority applies to any information governed by the Health Insurance Portability and Accountability Act of 1996 (HIPAA), 42 U.S.C. 1320d and 45 CFR 160 through 164. I authorize any physician, health care professional, dentist, health plan, hospital, clinic, laboratory, pharmacy, or other covered health care provider, any insurance company, and the Medical Information Bureau, Inc. or other health care clearinghouse that has provided treatment or services to my child, or that has paid for or is seeking payment from me for such services, to give, disclose and release to my agent, without restriction, all of my child’s individually identifiable health information and medical records regarding any past, present or future medical or mental health condition, including all information relating to the diagnosis of HIV/AIDS, sexually transmitted diseases, mental illness, and drug or alcohol abuse. The authority given my agent shall supersede any other agreement that I may have made with my child’s health care providers to restrict access to or disclosure of my child’s individually identifiable health information. The authority given my agent has no expiration date and shall expire only in the event that I revoke the authority in writing and deliver it to my child’s health care provider.

Witness my signature this the day of , 20.

STATE OF

COUNTY OF

Personally appeared before me, the undersigned authority in and for the said County and State, on this day of , 20, within my jurisdiction, the within-named , who acknowledged that he executed the above and foregoing instrument.