Healthcare Signature IEP Form

HEALTHCARE SIGNATURE IEP FORM

Student / Patient Information

Emergency Contact

Insurance Information

Medical History & Current Status

Health Services Requested / School Health Plan

The undersigned consents to the provision of the following school health services as identified in the student's Individualized Education Program (IEP) or 504 Plan. Select all that apply:

Consent and Authorization

I hereby authorize licensed school health personnel and designated staff to perform the services described in this form in accordance with the student's IEP or health plan. I understand that services will be provided in a manner consistent with professional standards and applicable policies. I acknowledge that I have been informed of the nature and purpose of the services, potential risks and benefits, and alternatives to the proposed services.

I understand that I may revoke this authorization at any time by submitting written notice to the school nurse or school administrator, except to the extent that the school has already taken action in reliance on this authorization. Revocation does not affect disclosures already made in reliance on this authorization.

Authorization effective date: — Authorization expiration date:

Release of Records & HIPAA Acknowledgment

By signing below, I authorize release and exchange of pertinent health information between the school and the student's health care providers, including physicians, hospitals, therapists, and insurers, to the extent necessary for coordination of care and implementation of the IEP health plan. This authorization includes immunization records, medication information, nursing assessments, and relevant medical reports.

I acknowledge that I have been provided with information about the privacy of health information and understand that my child's protected health information will be used and disclosed for the purposes described above.

Parent / Guardian / Adult Student Certification

I certify that the information provided on this form is accurate to the best of my knowledge. I understand that failure to provide complete information may affect provision of safe and appropriate services. I authorize the school to share information with emergency responders if necessary for the student's safety.

Certification: By signing above I affirm that I am authorized to provide consent for the student named in this form. I understand that this authorization is valid only for the duration specified unless revoked in writing, and that a copy of this form is as valid as the original.

Sign Now