Immunization Records
by Kara Throssell
April 22, 2008
Nurse Jen would like the parents to know about a new program that will help doctors and schools access their children's immunization records. The records will be available on a state immunization web site that only schools and doctors can look at. It will be a lifelong record of the students immunizations for future reference. Nurse Jen would like for parents to fill out this form for each child and return them to the school. If you have any questions you can contact her at the high school.
AUTHORIZATION FOR RELEASE OF HEALTH CARE INFORMATION
School: __________________________________________
Name of Student: _________________________________________
Address: __________________________________________
Phone: __________________ Date of Birth________________
Name of Parent or Guardian: _________________________________
Relationship to Student: ___________________________________
Address (if different than above): ________________________________
Phone (if different than above): ___________________________
I hereby authorize ______________________ to release immunization information in his/her/their possession relating to the above-named Student to:
__ ___________________ County Health Department
__ ______________________________ (Health Provider/Physician)
__ _______________________________ (USD _______/ School Official)
__ Kansas Immunization Registry (Immunization information disclosed to the Kansas Immunization Registry will be used for purposes of assessment and reporting to prevent disease.)
I affirm that I am authorized to consent of release of medical information on behalf of the student. I understand that this authorization will expire when the Student is no longer enrolled in the above-named and that I may revoke this authorization in writing at any time.
Parent / Guardian Signature: ____________________________ Date: _______________
The foregoing was acknowledged before me this _____ day of ________________, 20____.
By: ________________
