School Re-entry Referral

Date of Birth-DOB                                                  MRN#                                                                    Account/HAR#                                                     

(Please complete top half of this form)	PATIENT IDENTIFICATION

**This signed parental permission allows access to this child’s medical records and allows communication with a  school staff and child’s physician(s) (PERMISSION FORM MUST BE SIGNED BY PARENT/GUARDIAN; see PAGE 2 )**

Date of Referral:	Referral from:
Name: 	 Title: 	
Child’s Diagnosis:	Location: 	

Is this a new diagnosis?   Yes 	

No 	

Phone #: 	

Name of School:	Specialty Physician:
Grade: 		Office phone #: 	 Fax #: 	
County/School district:
Contact person at school: 		Parent Name:
Anticipated return to school date: 		Best Contact Phone #:

Healthcare needs at school / Type of health services, limitations or information requested:

**********************Fax referral to School Re-entry Program as listed below**********************
Please fax forms to:	Egleston Campus:	404-785-1526
Scottish Rite Campus:   404-785-5845
Outcome: (For Case Manager’s Use):

AUTHORIZATION TO RELEASE PROTECTED HEALTH INFORMATION

*	*
(PRINT PATIENT’S Full Name)	(PATIENT’S Date of Birth)
*	*
(PRINT name of Parent/Legal Guardian, or Patient (if 18 years of age or older)	(DAY Phone Number & Area Code)

Check (✓) one. I am the   0 Patient (must be 18 years of age or older)  0 Parent	0 Legal Guardian with custody (please state relationship to the patient)   		

0 Call to pick up records:	OR	0 Mail records to:

(DAY Phone Number & Area Code)	PRINT Name of Individual(s) or Agency
PRINT (Street Address or Box Number) PRINT (City, State and Zip Code)

•    I place no limitations on history or illness (including HIV and/or AIDS, genetic, drug dependency or psychiatric information) or diagnostic and therapeutic information, including any treatment for alcohol, drug abuse, or psychiatric disorders.
•    I authorize the inspection of the above information by the above named agency/person and/or to the furnishing of a photostat or other copies.
•    I understand that unless otherwise limited by state or federal regulation, I may withdraw this consent at any time by submitting my withdrawal request in writing. The withdrawal of this authorization does not affect any health information disclosed prior to Children's Healthcare of Atlanta receiving a written notice of withdrawal.
•    I hereby release Children’s Healthcare of Atlanta and its officers, directors, agents, and employees from any and all liabilities, responsibilities, damages, losses, and claims which might arise from the release of the information authorized above.
•    In furtherance of this authorization, I do hereby waive all provisions of the law and privileges related to the disclosures hereby authorized.
•    I hereby acknowledge that I have read (or had someone read to me) the above statements, and that I fully understand the above statements, and do expressly and voluntarily authorize the disclosure of this medical information to the individual or agency named above.
Check (✓) treatment location(s) from which you would like records released:

0 Children’s at Scottish Rite
0 Children’s at Hughes Spalding
0  Satellite Facility (list locations):   	

0 Children’s at Egleston
0 Marcus Autism Center
[2] All of these locations

THE FOLLOWING INFORMATION IS TO BE RELEASED Check (✓) Correct Document(s)
0 ABSTRACT: This option includes; autopsy report, clinic notes, consultations, discharge summary, emergency room record, face sheet, history & physical exam, laboratory reports, neuropsychological reports, operative reports, pathology, psychosocial notes, radiology reports, rehabilitation records, therapy notes.
0 EMERGENCY ROOM RECORD	[2] ENTIRE RECORD WITH NURSING FLOWSHEETS
0 ENTIRE RECORD WITHOUT NURSING FLOWSHEETS
0 OTHERS (Specify): 	
RECORDS DISTRIBUTED:	0 CD (when available*)	0 PAPER
* When choosing to have records released on CD, your total cost will be reduced to 50% of the total per page cost of your request.

Applicable Dates/Encounters (Specify)  	

The purpose for which this release is being requested is:	[2] Continuing Medical Care	0 Legal Action/Review
0 Insurance Reimbursement	0 Others (Specify)  	
0 Undeclared (at the request of the below signed)
Any disclosure of medical information by the recipient(s) is prohibited except when implicit in the purpose of this authorization. This authorization expires 	(insert applicable date or event or insert “no expiration designated”)
or in 6 months (12 months for school requests), whichever is shorter, and no further use/disclosures as described above may be made after the expiration. Authorizations apply only for medical records for specified treatment dates prior to and on the date of signature, unless otherwise specified.  Specified exceptions for future-dated releases are:    [2] School    0 Other  	

*Signature:  		*Date:  	

INTERNAL USE ONLY

0 Faxed	0 Mailed	0 Pick-up/Called:  	   Date:  	  Initials: