Release of Information Consent 06.25.2015

______Family

______Address

______City, State, Zip

Enter Local tiny-k Program specific info here ______Child’s Name

______DOB

I, ______, understand that the Kansas Infant Toddler Services is a network of local tiny-k programs that provides early intervention services and exchanges information for the purpose of serving my child and our family.

I authorize Kansas Infant Toddler Services’ local tiny-k Programs to obtain and release my child’s information to and from the following (Checking the boxes affirms consent) for the purpose of: ______

 Kansas Department for Children and Families  Physician______ Hospital ______ Physician______ Hospital ______ Audiologist______ Parents As Teachers  Medicaid/KanCare  Public School District #______for the purpose of  TRICARE transition  Kansas Deaf Blind Project  KSDE for sharing of EI record from cradle to career  WIC (0-21).  CDDO ______ Kansas State School for the Deaf  Sound Beginnings  Kansas Instructional Support Network  Early Head Start  Kansas State School for the Blind  Head Start  Case Worker______ Other______ Childcare Provider______ Other______ Other______

 I authorize KDHE to share my child’s information among programs in the Kansas Infant Toddlers Services system statewide.

 I understand these medical records may be protected by Federal and State Statutes and Regulations, which determine the extent and nature of the information, which may be disclosed pursuant to this organization.

 These records include medical, educational, social, psychological, and demographic information. Please indicate any specific information that you do not want released: ______.

 I understand that once released, my information may be disclosed and may no longer be protected under the Health Insurance Portability and Accountability Act (HIPPA), but will not be re-disclosed by the local tiny-k program, in accordance with the Family Educational Rights and Privacy Act (FERPA).

Parent(s)/Guardian Acknowledgment and Statement of Consent I acknowledge being provided a copy of the Child and Family Rights and the Kansas ITS Complaints Process – Kansas Infant Toddler Services. This information has been explained to me and I understand it. As discussed in this information, I have the right to contact the Kansas Department of Health and Environment at 785.296.6135 or 1.800.332.6262 and make an informal complaint, formal written complaint, request mediation and/or an impartial due process hearing should I disagree with the above proposed or refused action(s). For more information, I may also consult the Kansas Infant Toddler Services website at http://www.ksits.org/families.htm

I do hereby give this consent to the release of my child’s records described above freely and voluntarily. This consent expires in one year from date signed or upon parent/guardian’s request. I also understand that I may revoke this authorization in writing at any time. All copies of this form are valid.

Kansas Infant Toddler Services and the local tiny-k programs shall respect the privacy of children served and hold in confidence all information obtained in the course of professional services. Each agency will employ a Code of Ethics to assure a professional attitude, which upholds confidentiality toward children and their families.

______Parent/Guardian Signature Date

______

Note: Parents are to receive a copy of this form. Release of Information Consent 06.25.2015

Parent/Guardian Signature Date

Note: Parents are to receive a copy of this form.