Get 1196 P Auth To Use Disclose Ed Protected Health Info - Ode State Or

Filling out the 1196 P Auth To Use Disclose Ed Protected Health Info is essential for authorizing the sharing of educational and protected health information. This guide provides clear, step-by-step instructions to help you complete the form accurately and efficiently.

Follow the steps to complete the form online

1. Click ‘Get Form’ button to obtain the form and open it in the editor.
2. In Box 1, enter the full legal name of the student or child, including any middle names. Fill in other names used by the child, such as nicknames, and their date of birth. Then, provide the name and address of the healthcare provider authorized to send or receive the information. Specify the school or program name and address as well.
3. In Box 2, mark all relevant boxes to indicate the purposes for which the educational and protected health information will be used, such as determining eligibility for special education or developing an individualized education program.
4. In Box 3, indicate which specific medical or educational records are being requested. Check all applicable boxes and specify any that are not listed by selecting the 'other' option.
5. For Box 4, if any of the specific records listed, like mental health information, are needed, ensure you specify the record required, and initial next to each one to authorize this request.
6. Box 5 outlines your rights regarding this authorization. Read it carefully to understand that the authorization is voluntary and that you can request a copy of the form after signing. Note that you can revoke this authorization at any time.
7. In Box 6, the parent or legal guardian must sign the form. Include the date of signature and indicate the relationship to the child if signing as a guardian.
8. Finally, in Box 7, fill in the expiration date for the authorization, which should not exceed one year from the date signed.
9. Once completed, you can save changes, download, print, or share the form as needed.

Complete your document online today to ensure the proper handling of educational and health information!