Consent for Release of Information

Student Name(Required)

First Last

By completing and signing this form, you hereby authorize Map Academy Staff to disclose to/receive from the Provider listed below regarding the student listed above.

Provider Name(Required)

Provider Address(Required)

Street Address City State ZIP Code

Provider Phone(Required)

Student Date of Birth(Required)

Is the student over 18?(Required)

Yes

Check Areas of Release

Other Areas

Reason for release:

To facilitate development of appropriate treatment plan

To coordinate services

Other (specify below)

Other Reasons

I understand that I may revoke this release at any time. This release will expire one year from today’s date or as otherwise specified below. To the extent that my medical record contains information regarding drug or alcohol treatment that is protected by Federal Regulations 42CFR Part 2, I authorize disclosure of such information.

Alternative Expiration (if not a year)

Student's Signature

Parent/Guardian's Signature