TVUSD Authorization for Disclosure of Medical Information

Temecula Valley Unified School District AUTHORIZATION FOR USE AND /OR DISCLOSURE FOR INFORMATION Name of student (list other names used) Medical Record Number (if applicable) Date of Birth Address of student Phone No. Other Phone No. I authorize the... More

Temecula Valley Unified School District AUTHORIZATION FOR USE AND /OR DISCLOSURE FOR INFORMATION Name of student (list other names used) Medical Record Number (if applicable) Date of Birth Address of student Phone No. Other Phone No. I authorize the following individual or organization to disclose the above named individual s medical/educational information as described below: Individual or Organization Disclosing Information: Individual or Organization Receiving Information: Disclosing Party Receiving party Address Address City, State, Zip Code City, State, Zip Code Telephone: Fax: Telephone: Fax: Duration: This authorization shall become effective immediately and shall remain in effect until __________ (date) or for one year from the date of signature if no date is entered. Revocation: I understand that I have the right to revoke this authorization, in writing, at any time by sending such written notification to the releasing agency. Written revocation will be effective upon rece Less