Basically, this form allows the pediatrician to send otherwise HIPPA-protected health information...LIKE VACCINATION STATUS...to the schools, who can then send it to anyone they damn well please.
This is what I was given at yesterday's well-child check-up for my teenager. It is now apparently standard, and they give this form for you to fill out and sign, with no explanation whatsoever--and they don't tell you that you don't have to fill it out, either.
Note the bolded portion (bolding mine):
RELEASE OF PROTECTED HEALTH INFORMATION (PHI) TO SCHOOLS
I HEREBY AUTHORIZE _____________(Name of pediatric practice) to release information form the record of
Patient_____________, Date of Birth ____________ to the following school:
School Main Phone Number
The records to be released (identify all that apply):
__Immunization Records __Medical Excuse from School __Last Well Child Care Visit Exam
__ Prescribed Medications __Other:________________________________
HIV, Behavioral Health, and Drug and Alcohol Treatment contained in the parts of the record(s) indicated above will be released through the Authorization unless I request otherwise by checking here: __
I understand the following:
* My child's health records will not be released to any school unless permission is provided herein as evidenced by my signature below:
*Only those items checked off will be released. Only under true health care emergencies in which my child's health is at risk, will additional information be released without my authorization.
*The health records released by ________ (pediatrician) may be re-disclosed by the school. _____(pediatrician), it's staff/employees/physicians have no responsibility or liability for such re-disclosure.
*This Authorization is in effect for a period of 1 year from the date I sign it, unless I revoke my authorization as described below.
*I have the right to revoke this Authorization at any time by sending a written request to _______ (pediatrician) at the following address: __________________________.
*That any decision to revoke this Authorization does not apply to records already released prior to the date of the receipt of my request to revoke the Authorization.
*That ______ (pediatrician) will not condition treatment, payment, enrollment, or eligibility for benefits on whether I sign this authorization or not.
*That I am entitled to a copy of this completed Authorization form.
*That ______(pediatrician) will not fax health information to a school unless there is a true health care emergency.
Parent/Legal Guardian Signature Date
Parent/Legal Guardian Name (Please Print or Type)