Release of Information

Missouri School for the Blind
Release of Information Form

I understand that Outreach at Missouri School for the Blind offers a variety of services and benefits. Each agency must have specific information in order to provide these services and benefits and protect the student's information.

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* 1. Full name of the child.

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* 2. I understand the following:

The purposes of the exchanged information as described in the text above.

I have the right to inspect and receive a copy of the information to be shared.

I am providing my consent voluntarily, and I understand the information on this form.

I have a right to revoke this release at any time.

If I revoke this release, I must do so in writing and present my written revocation to Outreach Services, Missouri School for the Blind, 3815 Magnolia Ave, St. Louis, MO 63110.

Actions already taken based on this release, prior to revocation, will not be affected.

The release of information will remain in effect — unless I specify an expiration date in the comments of this form.

By clicking "I agree," you agree to the statements written above.

I agree to the statements written above.

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* 3. Enter parent/guardian contact information.

Name *

Relationship to Child *

Address *

Address 2

City/Town *

State/Province *

ZIP/Postal Code *

Email Address *

Phone Number *

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* 4. The purpose of the exchanged/shared information is to:

Perform a Functional Vision Evaluation

Plan and provide services

Other (please specify)

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* 5. This consent includes the following type of information:

Eye report/ophthalmological reports

Hearing and audiological reports

Individual Education Plan/Individual Family Service Plan

Review of Existing Data

Other health and medical records

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* 6. Information exchanged/shared between Outreach at Missouri School for the Blind and the provider below:

Provider/School/Agency/Eye doctor name

Address

Phone

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* 7. By typing my name below, I give my informed consent and give permission for my child’s name and pertinent data to be exchanged.

Yes, I agree and give my informed consent of this exchange of information.

Type your name below as an electronic signature.

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* 8. Comments? (Expiration date may be included here.)

Missouri School for the Blind
Outreach Services
3815 Magnolia Avenue
St. Louis, MO 63110

Release of Information

Missouri School for the BlindRelease of Information Form

Question Title

* 1. Full name of the child.

Question Title

Question Title

* 3. Enter parent/guardian contact information.

Question Title

* 4. The purpose of the exchanged/shared information is to:

Question Title

* 5. This consent includes the following type of information:

Question Title

* 6. Information exchanged/shared between Outreach at Missouri School for the Blind and the provider below:

Question Title

* 7. By typing my name below, I give my informed consent and give permission for my child’s name and pertinent data to be exchanged.

Question Title

* 8. Comments? (Expiration date may be included here.)

Missouri School for the Blind
Release of Information Form