Authorization for Release of Information

This form is intended to be used by child care programs when they enroll a child with a special health care need to communicate directly with the child’s health care provider. Communication between parents/guardians, the child care program and the primary care provider (medical home) requires the free exchange of protected medical information. Confidentiality laws state that parents/guardians must give permission to release protected medical information about their child.

Parents/guardians should be encouraged to sign the “Authorization for Release of Information” form to enable child care staff to communicate directly with the child’s medical home/primary care provider for information or questions about the care of a child with a special medical, developmental or behavioral need.  This form is from Model Child Care Health Policies, 5th Edition, available on the ECELS website under the Publications tab.  Reviewed and reaffirmed 6/2018.