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AUTHORIZATION
TO RELEASE HEALTH CARE INFORMATION
To: [CHILD'S PHYSICIAN]
For: [CHILD'S NAME], minor
I request and authorize you to forward the medical records
and other health care information identified below in your possession or control
to:
Name:[PHYSICIAN DURING INDEPENDENT MEDICAL
EVALUATION]
Address:
-
This Authorization includes all reports, tests, records and
observations pertaining to the patients medical history, condition, treatment,
diagnosis, prognosis, and etiology except for items connected with:
- HIV (AIDS
virus)
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Sexually transmitted diseases
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Psychiatric disorders / mental health
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Drug and/or alcohol use.
- [PHYSICIAN NAME] is hereby
authorized to discuss only her medical history, condition, treatments,
diagnosis, and prognosis that addresses accommodations needed under Section 504
Requests (Rehabilitation Act of 1973), Americans With Disabilities Act and
Individuals with Disabilities Education Act with the two named representatives
of [School District], [PERSON A] and [PERSON B], provided
within one week of any discussion that complete written summaries of all
discussion be forwarded to [CHILD's PHYSICIAN] and to [CHILD'S LAWYER , SUPPLY ADDRESS]
- That this authorization is strictly conditional that the physician shall
preface all written reports with a written declaration citing their experience
(See below). Without such a declaration, no authorization is granted.
- This authorization expires six weeks after the signature date.
Parent Signature: ______________________________________
Date: ________________________________
Physician’s Declaration
of Relevant Experience
I certified that the following is true:
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Number of patients that I have diagnosis with Hughes
Syndrome or its variants |
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Number of patients that I have diagnosis with Chronic
Fatigue Syndrome: |
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Number of patients that I have diagnosis with Chemical
Sensitivity: |
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Number of patient-years that I have treated individuals
with Hughes Syndrome or its variants: |
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Number of patient-years that I have treated individuals
with Chronic Fatigue Syndrome |
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Number of patient-years that I have treated individuals
with Chemical Sensitivity |
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Number of patients that I have successfully eliminated
or made symptom free with Hughes Syndrome or its variants: |
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Number of patients that I have successfully eliminated
or made symptom free with Chronic Fatigue Syndrome |
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Number of patients that I have successfully eliminated
or made symptom free from Chemical Sensitivity |
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Number of courses/classes/conferences that I have
attended dealing exclusively with Hughes Syndrome or its variants |
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Number of courses/classes/conferences that I have
attended dealing exclusively with Chronic Fatigue Syndrome |
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Number of courses/classes/conferences that I have
attended dealing exclusively with Chemical Sensitivity |
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Physician Name _______________________
Signature _________________________
Date: ___________________
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