Healthcare Special Education Consent Form

Healthcare Special Education Consent Form

Identification

Student/Patient Name:

Date of Birth:    Gender:    Student ID (if applicable):

Insurance Information

Medical History (Summary)

Requested Special Education Healthcare Services

The undersigned authorizes the provision of the following specialized healthcare and related services as part of the student's special education program. Please select all services to be provided:

Speech-Language Therapy
Occupational Therapy
Physical Therapy
Behavioral Intervention / ABA
Skilled Nursing / Health Services
Other (describe below)

Scope, Risks, Benefits and Alternatives

Scope of Services: The services authorized herein shall include direct therapy, assessment, consultations with school personnel, and formulation of individualized goals and accommodations as appropriate to the student's needs. Services may be provided in school, clinic, or community settings as determined by the planning team.

Risks and Potential Complications: The undersigned acknowledges that while most special education healthcare interventions are non-invasive, potential risks may include temporary discomfort, fatigue, increased frustration, minor swelling or soreness with physical interventions, or unforeseen medical reactions. Skilled nursing procedures may carry additional risks which will be described prior to implementation. The facility/provider will take reasonable steps to minimize foreseeable risks.

Expected Benefits and Alternatives: Benefits may include improved communication, functional mobility, self-care skills, and behavioral functioning. Alternatives to the recommended services include modified classroom supports, non-specialized interventions, or deferred services; refusal of services may result in lack of progress toward objectives identified in the individualized education plan.

Authorization to Disclose and Share Health Information

I authorize the release and exchange of educational and healthcare information related to the services outlined above between the following parties as necessary for assessment, treatment planning, implementation of services, and billing: school district personnel, contracted therapists, physicians, and insurance payors. Information to be shared may include evaluations, progress notes, medication lists, and service delivery records.

This authorization includes disclosure of health and educational records for the sole purposes described above. I understand that information disclosed under this authorization may include sensitive health information. I understand that this authorization is voluntary and that refusal to sign will not affect the patient's right to receive treatment, unless otherwise allowed by law.

Duration and Revocation

This authorization is effective beginning on: and will expire on: unless earlier revoked in writing by the undersigned. Revocation does not apply to information already released under this authorization prior to receipt of written revocation.

Acknowledgments and Certifications

By signing below, I certify that I am the student (if age-appropriate) or the parent/legal guardian or authorized representative of the student and have the authority to consent to special education healthcare services and to authorize disclosure of protected health information as set forth herein. I understand the nature and purpose of the services, the risks and benefits, and the alternatives.

I understand that I may withdraw this consent at any time by providing written notice to the provider or school district, except to the extent that action has already been taken in reliance on this consent. I understand that any supplied insurance information may be used for billing and payment purposes and that I may be responsible for charges not covered by insurance.

I acknowledge receipt of the applicable privacy practices and understand how my or my child's protected health information will be used and disclosed in connection with these services.

I acknowledge that I have read and understand the above statements and authorize the services and disclosures described in this form.

Additional Instructions / Provider Notes

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