"Parental Permission to Obtain Information" - New Mexico

This fillable ""parental Permission to Obtain Information" - New Mexico" is a document issued by the New Mexico Department of Health specifically for New Mexico residents.

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PARENTAL PERMISSION TO OBTAIN INFORMATION
Parent Permission t
o Obtain Information
I, __________________________________________________________, give consent to the physician,
(Parent/Guardian Name)
hospital, clinic, agency or school specified below to release information concerning the diagnosis and/or
treatment of _______________________________________________, _________________________,
)
(Student Name)
(Date of Birth
Clinic/Hospital# ___________________________ and/or Medicaid # ___________________________
to the ___________________________________ School District. This information will be used in
coordinating the educational program, ancillary therapy and related school health services for this child.
This authorization for release of information being requested is effective immediately and shall be valid for
one year from the date signed.
Specific information being requested: ___________________________________________________
____________________________________________________________________________________
Address of party from whom information is being
This information is to be released to:
requested:
_____________________________________________
____________________________________________
(Name)
(Name)
_____________________________________________
___________________________________________
(Street Address)
(Street Address)
_____________________________________________
___________________________________________
(City, State, Zip)
(City, State, Zip)
___________________________________________
____________________________________________
(Parent/Guardian Signature)
(Relationship to Student)
___________________________________________
(Date)
PARENTAL PERMISSION TO OBTAIN INFORMATION
Parent Permission t
o Obtain Information
I, __________________________________________________________, give consent to the physician,
(Parent/Guardian Name)
hospital, clinic, agency or school specified below to release information concerning the diagnosis and/or
treatment of _______________________________________________, _________________________,
)
(Student Name)
(Date of Birth
Clinic/Hospital# ___________________________ and/or Medicaid # ___________________________
to the ___________________________________ School District. This information will be used in
coordinating the educational program, ancillary therapy and related school health services for this child.
This authorization for release of information being requested is effective immediately and shall be valid for
one year from the date signed.
Specific information being requested: ___________________________________________________
____________________________________________________________________________________
Address of party from whom information is being
This information is to be released to:
requested:
_____________________________________________
____________________________________________
(Name)
(Name)
_____________________________________________
___________________________________________
(Street Address)
(Street Address)
_____________________________________________
___________________________________________
(City, State, Zip)
(City, State, Zip)
___________________________________________
____________________________________________
(Parent/Guardian Signature)
(Relationship to Student)
___________________________________________
(Date)
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