WPS Authorization for Release of Information

Authorization for Release of Information

Health Services at Wayzata Public Schools, ISD284
Please complete this form to submit a Health Services electronic release of information for Wayzata Public Schools students.

To submit a Wayzata High School Student Support Services release of information for students in grades 9-12, please use the Wayzata High School Release of Information form.
Student's Name*

First NameLast Name
Student's Date of Birth*

MonthDayYear
Date
Student's Grade*
Student's ID Number
Student's School*
Parent/Guardian or Legal Representative Name*

First NameLast Name
Parent/Guardian or Legal Representative Phone Number*
Please enter a valid phone number.
Parent/Guardian or Legal Representative Email Address*
example@example.com
I, named above, authorize Wayzata Public Schools, ISD 284,*

to release the specific information identified below to:to obtain specific information identified below from:
Name of individual or entity:*
Provider Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Release of:*

health recordsmedical reportschemical abuse / dependency reportpsychological reportspsychiatric reportteacher, counselor, staff observationsspecial education recordssocial work reportOther
For the purpose of:*
I understand that this authorization takes effect the day I sign it, cannot exceed one year, and expires on:*

MonthDayYear
Date
I further understand:
- I may refuse to sign this authorization and it will not affect my child’s ability to receive educational services,
- the laws that protect the information identified on this release, in some situations, may allow or require this entity to re-disclose this information, but only as permitted by law (Health Insurance Portability and Accountability Act [HIPAA], Family Educational Rights and Privacy Act [FERPA], Minnesota Government Data Practices Act [MGDPA or Chapter 13]),
- a digital version of this release form is as valid as an original, and
- I will receive a copy of this authorization.
Signature*

Clear
Should be Empty: