Healthcare IEP Signature Form

HEALTHCARE IEP SIGNATURE FORM

Student / Patient Information

Student/Patient Name:

Date of Birth:   Gender:

School / Facility Information

Insurance Information (if applicable)

Requested Health Services / IEP Health-Related Services

The undersigned authorizes the school/district and designated health care personnel to provide the following services as part of the student's Individualized Education Program (IEP). Select all that apply:

Nursing services (assessments, care planning, procedures)

Administration of medication or medical treatments

Therapeutic services (speech, occupational, physical therapy)

Durable medical equipment / assistive devices

Routine health monitoring / blood glucose, seizure precautions, etc.

Medical History and Current Health Status

Authorization to Release and Exchange Health Information

I authorize the release and exchange of relevant health information between the school/district and the following health care providers, agencies, or individuals for purposes directly related to the IEP and provision of health services:

This authorization includes disclosure of medical, developmental, therapeutic, and medication information necessary for delivery and coordination of health-related services under the IEP. Information disclosed under this authorization may include but is not limited to: medication lists, allergy and immunization information, assessment findings, treatment plans, and nursing notes.

Consent for Treatment and Administration of Medication

By signing below, I give permission for the school/district and authorized health personnel to administer medications, perform routine health procedures, and provide health-related interventions identified in the IEP. I understand that medications and procedures will be administered according to the prescribing provider's written orders and school policy. I acknowledge that I have the right to receive a copy of all written instructions related to medications and procedures.

I understand there are risks and benefits to treatments and procedures. Risks may include but are not limited to allergic reaction, improper administration, or ineffective outcome. Benefits include improved health, safety, or functional ability required for educational access. I understand I may refuse or withdraw this authorization at any time by submitting written notice to the school/district, except to the extent action has already been taken based on this authorization.

I acknowledge that I have read and understand the risks, benefits, and the right to withdraw this authorization.

HIPAA and Privacy Acknowledgment

I acknowledge that the information disclosed pursuant to this form may be protected health information under applicable privacy laws. The school/district and authorized recipients will protect and use such information only as necessary for IEP development, service provision, and program monitoring. I understand that information disclosed pursuant to this authorization may be re-disclosed by the recipient and may no longer be protected by privacy rules.

I acknowledge receipt of the privacy notice and authorize disclosure as described above.

Certification and Consent

By signing below I certify that I am the parent or legal guardian of the student named above, or the student is age 18 or older and is competent to sign. I certify that the information provided on this form is true and accurate to the best of my knowledge. I authorize the school/district to perform the health services identified in the student’s IEP and to share necessary health information with authorized personnel and agencies as stated above.

Certification: I understand that signing this form authorizes electronic or paper copies of this authorization to be treated as originals. I understand that I may revoke this authorization at any time in writing, except to the extent that action has already been taken in reliance on this authorization. Revocation should be submitted to the school/district health office or case manager.

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