"*" indicates required fields Student InformationMEDICAL RELEASE: Date Information Desired by:* Student Name* Date of Birth* Address (including City/State/Zip)* Phone*Release Medical Information FromProvider/Facility Name* Address* City/State/Zip* Phone*Release Medical Information To St. Joseph’s Indian School, PO Box 89 1301 N. Main St., Chamberlain, SD 57325 Phone: Julie Lepkowski, 605-234-3465; E-mail: julie.lepkowski@stjo.org Purpose of Release* School Admissions Other If other, please specify* Information to be ReleasedRelease Format Paper CD/DVD Release Method Mail Pick Up Email Fax Service Dates: From Birth To Present* Clinic Progress Notes Hospital Progress Notes History & Physical Consultation Notes ER Records Discharge Summary EKG/Cardiology Reports Pathology Reports Operative Reports Lab Reports Radiology Reports Radiology Images Substance Abuse Evals/Assmts Psychological Evals/Assmts Immunization Records Mental/Behavioral Health Records All Records Other If 'Other' is selected, please specify* AgreementI understand that I may revoke this authorization at any time by sending a written notice to St. Joseph’s Indian School. If this authorization has not been submitted, it will terminate one year from the date of my signature or at the end of the summer program. I hereby authorize the above facility/provider to disclose medical information concerning the above named patient to the party identified in the section titled “Release Information To.” I understand that the information to be released may include information regarding mental health, alcohol and drug usage, and HIV-related information. I understand that once the information is disclosed, it may be subject to re-disclosure by the recipient and may no longer be protected. I understand that this authorization is voluntary and that I may refuse to sign this authorization. Unless allowed by law, my refusal to sign will not affect my ability to obtain treatment, receive payment, or eligibility for benefits. This authorization will expire one year from the date of signing unless I indicate an event or earlier date here SignaturesI/We understand collection of this information does not mean that my/our child has been admitted to St. Joseph’s Indian School, but only that admission is being considered.Parent/Guardian Signature*Print Parent/Guardian Name* Relationship to child* (2) Parent/Guardian Signature(2) Print Parent/Guardian Name (2) Relationship to child Today's Date* MM slash DD slash YYYY Parent/Guardian Email*
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