Healthcare Transfer IEP Form

HEALTHCARE TRANSFER IEP FORM

Patient / Student Information

Patient Name:    Date of Birth:    Gender:

Phone:    Student ID / MRN:    Grade/Age:

Sending and Receiving Entities

Insurance and Billing (if applicable)

Medical History and Current Health Status

IEP-Related Health Services / Required Supports

Nursing services required (check applicable):
Medication administration    Tracheostomy care    Enteral tube feeding    Seizure monitoring/response

Therapy services (check and specify frequency):
Physical Therapy — Frequency:    Provider:
Occupational Therapy — Frequency:    Provider:
Speech-Language Therapy — Frequency:    Provider:

Medication Administration Record (MAR) Summary

Provide current MAR entries or summary below (name, dose, route, schedule, indication). If additional space is needed, attach a full MAR.

Attachments Transferred (check all that apply)

IEP or 504 Plan    Medical summary    Medication Administration Record (MAR)
Therapy evaluations/reports    Immunization record    Emergency Action Plan / Health Plan

Authorization to Release and Receive Health Information

I hereby authorize the releasing entity named above to disclose and forward to the receiving entity all health records, nursing notes, medication administration records, therapy reports, evaluations, IEP health goals, emergency plans, and immunization records that are necessary to ensure continuity of health services in the educational setting. This authorization specifically includes sensitive health information related to diagnoses, treatments, and therapy progress that are relevant to implementing the IEP.

Purpose of disclosure:

Effective date of this authorization:    Expiration date (if any):

I understand that I may revoke this authorization at any time by providing a written notice to the releasing entity, except to the extent that action has already been taken in reliance on this authorization. I understand that information disclosed pursuant to this authorization may be redisclosed by the recipient and may no longer be protected by state or federal privacy laws. I further understand that refusal to sign this authorization will not affect the patient’s right to receive treatment or educational services, except as otherwise provided by law.

I acknowledge that the records to be disclosed may include psychiatric, behavioral health, or substance use disorder information only if specifically indicated above. Such disclosures are limited to information necessary for the recipient to provide safe and appropriate educational and health services.

HIPAA / Privacy acknowledgment: I acknowledge that I have been informed of the nature of this release and the privacy protections that apply to my health information as described above.

Additional Instructions / Special Considerations

Sign Now