SCDHHS/IDEA PART C/01JUL2020/ALL PREVIOUS VERSIONS ARE VOID
CONSENT TO RELEASE AND/OR OBTAIN INFORMATION FORM
CONSENT TO RELEASE AND/OR
OBTAIN INFORMATION
SECTION 1: CHILD AND PARENT INFORMATION
SECTION 2: PURPOSE OF INFORMATION REQUESTED OR RELEASED
Request for information or release is for purpose(s) of:
IDEA/Part C Eligibility
IDEA/Part C Eligibility
Status
IFSP development or
review
Other IDEA/Part C
service planning
Information to be requested or released:
SECTION 3: PARENT ACKNOWLEDGEMENTS AND CONSENT
My signature on this form indicates that I:
Authorize the individual, program, organization and/or entity listed above to disclose and/or obtain specific health/medical and
educational information from the records of my child.
Understand that I may request a copy of any information that is shared or received.
Agree that a copy of this consent may be treated as an original.
Understand that if the record contains information relating to HIV infection, AIDS or AIDS-related conditions, alcohol abuse,
drug abuse, or genetic testing, this disclosure may include that information.
Understand that this information may be released securely in any of the following ways: fax, email, direct mail, texting, or by
telephone.
Understand that, while services will not be denied because of failure to sign this consent form, the inability to collect necessary
information may result in an inability to determine if my child is eligible for IDEA/Part C services.
Understand that I may revoke this consent in writing at any time. Any action taken prior to the date my consent is rescinded is legal
and binding.
Understand that if I fail to specify an expiration date or condition for this consent, it is valid for the period needed to fulfill its
purpose for up to one year.
LIMIT consent as follows (describe):
SECTION 4: SENDER AND RECIPIENT OF INFORMATION REQUESTED OR RELEASED
Information requested from released to:
Please RETURN requested information to:
*Required for the official record and any investigation of complaint(s). NOTE: IDEA/Part C records are protected from unauthorized disclosure under the Family
Educational Rights and Privacy Act (FERPA). Personally identifiable information protected by FERPA is specifically exempted from the privacy standards of the Health
Insurance Portability and Accountability Act (HIPAA). IDEA/Part C may disclose personally identifiable information from a record only on the condition that the party
to whom the information is disclosed will not disclose the information to any other party without the prior consent of the parent (34 CFR 99.33).
