HIPAA Authorization for Release of Health Information

Official school form

Permits limited, need-to-know sharing of your child's health information between your providers and school staff responsible for their care.

What this authorizes

Under the Health Insurance Portability and Accountability Act (HIPAA), I authorize the release and exchange of protected health information about the student named below between the student's healthcare providers and designated Solomon Heights Academy staff.

Information may include: allergies, chronic conditions, current medications, immunization records, emergency treatment instructions, and any physician directive affecting school participation.

How it is used and protected

Health information is shared only with staff who have a legitimate need to know in order to keep the student safe: the school office, the student's teachers, and any staff supervising off-campus activity.

Records are stored securely, kept separate from academic records, and are never sold, published, or shared with third parties for any purpose other than the student's health and safety.

Your rights

This authorization is voluntary. Care and enrollment are not conditioned on signing it, though refusal may limit our ability to respond to a health event.

You may revoke this authorization at any time by written notice to the school office. Revocation does not apply to information already disclosed in reliance on it.

This authorization expires one year from the signature date, or earlier upon written revocation.

Information to complete

Student full name *

Student date of birth *

Healthcare providers / clinics authorized to exchange information *

Information I am authorizing *

All health information relevant to school participation
Allergies and emergency instructions only
Immunization records only
Other (described below)

Any information I specifically exclude

I permit the student's teachers to be told about conditions affecting classroom safety.

Yes

I have read this authorization, understand my right to revoke it, and consent to the disclosures described.

Parent / guardian signature

Date

Solomon Heights Academy3200 NW 48th Street, Oklahoma City, Oklahoma 73112HIPAA Authorization for Release of Health Information

Return completed forms to the school office at 3200 NW 48th Street, Oklahoma City, Oklahoma 73112.