Fill and Sign the Guardianship Authorization Home Page the Superior Form

Authorization to School for Emergency Medical Treatment for Minor I, _________________________________________________ (Name of Parent or Guardian), of _________________________________________________ (street address, city, county, state, zip code), am the _________________________________________________ (father or mother or legal guardian) of _________________________________________________ (Name of Minor), a minor, of _________________________________________________ (street address, city, county, state, zip code) , who attends _________________________________________________ (Name of School), located at _________________________________________________ (street address, city, county, state, zip code). I hereby give my consent, if all reasonable attempts by authorized school personnel to contact me at _________________________________________________ (phone number) or _________________________________________________ (other parent or guardian) at _________________________________________________ (phone number) have been unsuccessful, for the following: 1. The administration of any treatment deemed necessary by _________________________________________________ (Name of Physician) or _________________________________________________ (Name of Dentist) or, if the appropriate practitioner is not available, by another licen sed physician or dentist; and 2. The transfer of _________________________________________________ (Name of Minor), to _________________________________________________ (Name of Hospital) or any hospital reasonably accessible. This authorization does not cover majo r surgery unless the medical opinions of two other licensed physicians concurring in th e 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 _________________________________________________ (Name of Minor) '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 tr eated as I would be with respect to my rights regarding the use and di sclosure of my child’s individually identifiable health information or other medical records. This release authority applies to any information governed by the Health Insu rance Portability and Account ability 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 Me dical Information Bureau, Inc. or other health care cl earinghouse 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 informati on 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 ag reement 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 th e authority in writing and deliver it to my child’s health care provider. Witness my signature this the __________ day of _________________________________________________, 20__________. ____________________________________ Name of Parent or Guardian 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 _______________________________ ____________________________ (Name of Parent or Guardian), who acknowledged that he executed the above and foregoing instrument. ____________________________________ NOTA RY P U BLIC My Commission Expires: