Release Medical Information From
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: email@example.com
Information to be Released
I 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.
I/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.