Authorization for the Release of Health Information
Patient Name:▁▁▁▁▁▁ Phone Number:▁▁▁▁▁▁
State:▁▁▁▁▁▁ Zip code:▁▁▁▁▁▁
Date of Birth (D.O.B.):▁▁▁▁▁▁
I hereby authorize,▁▁▁▁▁▁ to release my medical information to▁▁▁▁▁▁
Middletown Enlarged School District
223 Wisner Avenue
Middletown, NY 10940
ATTN: Medical records:
Phone number:▁▁▁▁▁▁ Fax number:▁▁▁▁▁▁
Authorization to Discuss Health Information:
By initialing here,▁▁▁▁ I hereby authorize:▁▁▁▁▁▁ to discuss my health information with Middletown School District Health Office.
TO BE READ AND SIGNED BY PATIENT/GUARDIAN:
I understand the following:
I may revoke this authorization at anytime by providing written notice to the school.
I am signing this authorization freely, under no undue stress from any individual to do so.
I acknowledge that I have had the opportunity to review this authorization and understand its intent and purpose.
Signature of Parent/Legal Guardian:▁▁▁▁▁▁ Date:▁▁▁▁▁▁