Authorization to Exchange Confidential Information
Client/Student/Patient's Name (required)
Your Email (required)
Your Social Security Number: (required)
Date of Birth (required)
I/we request and authorize
to exchange confidential information and records with:
Oklahoma School of Science and Mathematics
1141 North Lincoln Boulevard
Oklahoma City, OK 73104
This authorization applies to inspecting, copying, mailing, and discussing:
Health Care Information and RecordsEducational/School Information and RecordsFinancial Information and RecordsSocial Services Information and RecordsLegal Information and RecordsOther:
If you checked "Other," please enter here.
I/we also consent to the release of health care information and records relating to the testing, diagnosis and treatment of:
Mental illness and/or psychiatric disordersAlcohol and/or drug abuseSexually transmitted diseases, including HIV/AIDS
I/we understand that the purpose of the information to be released is to assist in helping OSSM staff as they consider the student’s ability to successfully function in a residential school setting. Some information which may be shared with relevant OSSM staff are: results of any psychiatric evaluation including diagnosis, specific treatment recommendations and, if applicable, summaries of on-going treatment status.
This authorization expires in one (1) year, but may be revoked at any time, except to the extent the holder of the information/records has already taken substantial action in reliance on the authorization. Any further disclosure may be made only as provided by law. A photocopy of this form is as valid as the original. I understand that the information and records to be released are protected under Federal Confidentiality Regulation and other federal law.
My/Our signature(s) below authorize(s) release of all such records and information.
Student Digital Signature (required)
Parent/Legal Guardian Digital Signature (required)
Oklahoma School of Science and Mathematics1141 N Lincoln BlvdOklahoma City, OK 73104(405) 521-6436