- 11/19/2013 Authorization for Medical Information
AUTHORIZATION FOR EXCHANGE OF CONFIDENTIAL
MEDICAL INFORMATION
Date :
Student Name: Birth Date:
School: Grade:
I hereby authorize the exchange of confidential records regarding the above named student between:
Everett Public Schools
and
Name of agency/physician/counselor/, etc
Street Address
City, State, Zip
Phone FAX number
Names of staff that will have my permission to access this
information:
Nurse:
Teacher:
School Psychologist:
Other:
Other:
Specific Information Requested:
and other information relevant to educati...
Authorization for Medical Information.pdf 
