Authorization for Release_Exchange of Information.pdf

Blanche Ames Elementary School Easton Middle School

48 Spooner St. North Easton, MA 02356 98 Columbus Ave, North Easton, MA 02356

Richardson Olmsted Elementary School Oliver Ames High School - Gr: 9-12

101 Lothrop St. North Easton, MA 02356 100 Lothrop st. North Easton, MA 02356

Authorization for Release/Exchange of Information

This form provides the Easton Public Schools with written permission to communicate with your

student’s outside team regarding your treatment (e.g. previous treating therapist, current health care

providers, etc)

Student Name:

Date of Birth:

Release of information between the Easton Public Schools and Person or Party - LISTED BELOW -

for the purpose of coordination of care:

I authorize my student’s school to release/exchange information to/from:

Name:

Agency/Role:

Email Address:

Phone Number:

Address:

This release will be valid until this expiration date:

All student information will be included (academic, social emotional, medical, etc) unless otherwise

stated.

This authorization may be revoked at any time.

Name of Parent/Guardian/Caregiver providing Authorization(print):

Name:

Relationship:

Signature of Patient, Client or Authorized person:

Date: