AUTHORIZATION FOR EXCHANGE OF CONFIDENTIALMEDICAL INFORMATIONDate :Student Name: Birth Date:School: Grade:I hereby authorize the exchange of confidential records regarding the above named student between:Everett Public SchoolsandName of agency/physician/counselor/, etcStreet AddressCity, State, ZipPhone FAX number Names of staff that will have my permission to access thisinformation:Nurse:Teacher:School Psychologist:Other:Other:Specific Information Requested:and other information relevant to educati...
Allowed
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