Healthcare CPSE Document

CPSE MEDICAL INFORMATION AND AUTHORIZATION

This form authorizes the release and exchange of medical and developmental information necessary for the Committee on Preschool Special Education (CPSE) to evaluate eligibility for early intervention or special education services, and to plan appropriate health-related supports. Completion of this form is voluntary but may be necessary to determine program eligibility and service provision.

Patient / Child Information

Date of Birth:    Gender:

Primary Phone:    Email:

Phone:    Relationship:

Insurance / Coverage

Policy / ID Number:    Group Number:

Subscriber Date of Birth:

Medical and Developmental History

Authorization to Release and Obtain Medical Records

I authorize the release and exchange of medical, developmental, educational, and psychological records and reports concerning the above-named child to and from the Committee on Preschool Special Education (CPSE), designated school district staff, and consultants participating in CPSE evaluations and service planning.

Purpose of Disclosure: Eligibility determination, functional assessment, service planning, coordination of care, and monitoring of health-related services provided through CPSE.

Entities Authorized to Release/Obtain Records:

I consent to the release of records including but not limited to: medical history, immunizations, progress notes, medication records, laboratory and imaging reports, therapy notes, and psychological evaluations as relevant to CPSE processes.

Authorization to Release for Behavioral Health / Substance Use Records (if applicable): Yes No

This authorization permits re-disclosure by recipients where permitted by law. I understand that information disclosed under this authorization may include sensitive information and may be subject to additional legal protections.

I understand that I may revoke this authorization at any time by providing written notice to the originating provider and to CPSE, except to the extent that action has already been taken in reliance on this authorization. Revocation does not affect disclosures made prior to receipt of written revocation.

This authorization will expire on: or upon termination of CPSE involvement, whichever occurs first.

Authorization for Evaluation and Treatment

I authorize CPSE and its designated evaluators and providers to conduct developmental and health-related evaluations and to provide or coordinate treatment/services determined to be necessary as part of CPSE planning. These services may include nursing supports, therapies (speech, occupational, physical), and behavior interventions specific to educational needs.

I understand that I have the right to refuse any recommended service or therapy. I further understand that consent for services is separate from consent to release records and that denial of consent for treatment will not affect my obligation to provide accurate information for eligibility determination.

Evaluation Authorized: Yes No

Treatment / Services Authorized: Speech Therapy Occupational Therapy Physical Therapy Nursing / Health Services Behavior Intervention / Support

HIPAA & Privacy Acknowledgment

I acknowledge that I have been informed of my rights under federal and state privacy laws and that information released pursuant to this authorization may be protected by the Health Insurance Portability and Accountability Act (HIPAA). I understand how this information will be used for CPSE purposes.

I acknowledge receipt of a copy of this Authorization: Yes No

Legal Certifications

By signing below, I certify that I am the parent or legal guardian of the child named above or otherwise have legal authority to consent on the child's behalf. I affirm that the information provided on this form is true and accurate to the best of my knowledge. I understand that signing this form authorizes disclosure of confidential information as described herein.

I understand that this authorization is voluntary and that services will not be conditioned on the execution of this form except where allowed by law. I further understand that this authorization may be revoked in writing at any time, except to the extent that action has already been taken in reliance on it.

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