Skip to main content

Release of Information Form

Refer A Child/Release of Information Form

Release of Information Form

Please complete this release of information so that it can be submitted with the referral.

First Name *
Middle *
Last Name *
Month
/
Day
/
Year
Country
Address Line 1 *
Address Line 2
City *
State/Province *
Postal Code *

For assistance to access community resources, I authorize to release all demographic, assessment, development, and treatment information of the above list as stated below:

Release From:

Country
Address Line 1 *
Address Line 2
City *
State/Province *
Postal Code *

Disclose Personal Health Information (PHI) To:

United Way 211 (d/b/a Help Me Grow)

Country
Address Line 1 *
Address Line 2
City *
State/Province *
Postal Code *

I understand this authorization may be revoked in writing at any time by doing so at the originating organization, except to the extent that action has been taken in reliance on this authorization. I further understand that the information disclosed pursuant to this authorization may be re-disclosed by the recipient and may no longer be protected by federal or state confidentiality regulations. The originating organization will not condition healthcare provision of this authorization.

By signing this release, you are consenting to allow Help Me Grow (UNMC/MMI) to discuss and coordinate care between you, and your child’s medical team.

This Authorization expires after one year from date of release or once the patient reaches the age of nine years old.

Authorized by:

First Name *
Last Name *
Month
/
Day
/
Year
Signature checkbox

Pursuant to the Family Educational Rights and Privacy Act of 1974 (“FERPA”), I give my consent to authorize the release of the academic records and all personally identifiable information contained therein, including transcripts and IEPs of above listed patient from the school or school district listed below for the purpose of participation in the Help Me Grow program.

Education Records From:

Country
Address Line 1 *
Address Line 2
City *
State/Province *
Postal Code *

Disclose Personal Health Information (PHI) To:

United Way 211 (d/b/a Help Me Grow)

Country
Address Line 1 *
Address Line 2
City *
State/Province *
Postal Code *

Help Me Grow may send information to the patient’s school and communicate with school personnel to help secure community resources or to provide pertinent information to schools to assist with student needs.

This authorization expires after one year from date of release or once the student/child reaches the age of nine years old.

Authorized by:

First Name *
Last Name *
Month
/
Day
/
Year
Signature checkbox
MENU CLOSE