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AUTHORIZATION TO RELEASE HEALTH CARE INFORMATION

 To:       [CHILD'S PHYSICIAN]

 For:      [CHILD'S NAME], minor

 I request and authorize you to forward the medical records and other health care information identified below in your possession or control  to:

            Name:[PHYSICIAN DURING INDEPENDENT MEDICAL EVALUATION]

            Address:

  1. This Authorization includes all reports, tests, records and observations pertaining to the patients medical history, condition, treatment, diagnosis, prognosis, and etiology except for items connected with:
    1. HIV (AIDS virus)
    2. Sexually transmitted diseases
    3. Psychiatric disorders / mental health
    4. Drug and/or alcohol use.
  2. [PHYSICIAN NAME] is hereby authorized to discuss only her medical history, condition, treatments, diagnosis, and prognosis that addresses accommodations needed under Section 504 Requests (Rehabilitation Act of 1973), Americans With Disabilities Act and Individuals with Disabilities Education Act with the two named representatives of [School District], [PERSON A] and [PERSON B], provided within one week of any discussion that complete written summaries of all discussion be forwarded to [CHILD's PHYSICIAN] and to [CHILD'S LAWYER , SUPPLY ADDRESS]
  3. That this authorization is strictly conditional that the physician shall preface all written reports with a written declaration citing their experience (See below). Without such a declaration, no authorization is granted.

  4. This authorization expires six weeks after the signature date.

    Parent Signature: ______________________________________

    Date: ________________________________

                            Physician’s Declaration of Relevant Experience

    I certified that the following is true:

    Number of patients that I have diagnosis with Hughes Syndrome or its variants

     

    Number of patients that I have diagnosis with Chronic Fatigue Syndrome:

     

    Number of patients that I have diagnosis with Chemical Sensitivity:

     

    Number of patient-years that I have treated individuals with Hughes Syndrome or its variants:

     

    Number of patient-years that I have treated individuals with Chronic Fatigue Syndrome

     

    Number of patient-years that I have treated individuals with Chemical Sensitivity

     

    Number of patients that I have successfully eliminated or made symptom free with Hughes Syndrome or its variants:

     

    Number of patients that I have successfully eliminated or made symptom free with Chronic Fatigue Syndrome

     

    Number of patients that I have successfully eliminated or made symptom free from Chemical Sensitivity

     

    Number of courses/classes/conferences that I have attended dealing exclusively with Hughes Syndrome or its variants

     

    Number of courses/classes/conferences that I have attended dealing exclusively with Chronic Fatigue Syndrome

     

    Number of courses/classes/conferences that I have attended dealing exclusively with Chemical Sensitivity

     

    Physician Name _______________________

    Signature _________________________

    Date: ___________________

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