Consent To Share Asthma Action Plan And Information About My Child'S Asthma Form printable pdf download

Consent to Share Asthma Action Plan and Information about My Child's Asthma

Child's name: ________________________________________________________

School _____________________________________________ Grade___________

I, the parent or guardian ________________________________, agree that my child's Asthma

Action Plan (AAP) and other information about my child's asthma may be shared among those

noted below. I understand that this information will be used to help manage my child's asthma

when I am not with my child.

Check the box and write in the name of those you want to include in this consent:

Health Care Provider __________________________________________________

School Staff and School Health Office ____________________________________

Day care provider ____________________________________________________

Clinic or hospital _____________________________________________________

Coach ____________________________________________________________

Other ______________________________________________________________

How my child's privacy will be protected:

a. My child's health care provider must follow health information privacy laws.

b. My child's school and a coach who works for the school must follow school privacy laws.

c. Some people are not covered by privacy laws and it is possible they will not keep this

information private. This includes my child's day care provider, coach and others that I share

my child's asthma information with.

I have been told these key points:

a. I do not have to give my consent.

b. If I do not sign this consent, the quality of asthma care may be affected because other school

staff and the health care provider won't have all available information (since information is

not allowed to be shared without my consent), but it will not affect the other care my child

receives from school staff or their health care provider.

c. I may cancel my consent at any time. To cancel my consent, I need to send or deliver a letter

to the people listed above asking them to cancel my consent. I will provide my child's name

and sign my name.

d. This consent form expires in one year.

Signature of parent or guardian: ____________________________

Date: _________________

Note to health care provider: Please give this consent to the parent or guardian for them to sign and

their child's school.

This document complies with the requirements of the HIPAA (Health Insurance Portability & Accountability Act) Privacy Rule, and the FERPA (Family

Educational Rights & Privacy Act ) Regulations.

07/01/09

Consent To Share Asthma Action Plan And Information About My Child'S Asthma Form