Early ACCESSGuidance Specific to Early ACCESS
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| Demographic information | The Authorization pertains only to the child and cannot be used to request information for more than one member of a family. For each member of the family that information is requested, a separate Authorization must be completed. |
| Purpose of the release | The purpose of the release must be specified (e.g. evaluation for EA services, assessment, IFSP planning, etc.) |
| Specific information to be released | Parents are able to specify specific information they want shared with individuals, programs, organizations, or services. Those entities are to be listed on the second page of the Authorization. This Authorization allows the entities to share information with each other without requiring a separate authorization for each entity. Written copies of reports, etc. are to be sent to the Recipient as defined below.
Specific authorization is required for the release of mental health, sexually transmitted disease, substance abuse/chemical dependence, or HIV/AIDS records. If a parent/family member wants this information released, he/she will need to initial the line by the requested record. |
| Expiration of the Authorization | Authorizations are only valid for a maximum of one year. Parents may choose to have the release expire prior to one year. In that event, the expiration date needs to be specified. If a date is not inserted, the Authorization will automatically expire one year from the date of signature. The Authorization is voluntary and may be revoked in writing; however, this does not affect information shared prior to revocation. |
| Recipient information | This is to allow the Service Coordinator to collect information from the specified entities on the second page of the form to be a part of the IFSP. |
| Copies of the authorization | The original must be sent to the grantee to keep in the official record. A copy of the Authorization must be given to the family, listed entities, and kept as part of the IFSP record. Please check the appropriate box on the bottom of the form. |
| HIPAA/ FERPA information |
Once the health information is received, it becomes part of the child’s “educational record” since Early ACCESS is funded by Individuals with Disabilities in Education Act (IDEA). As part of the educational record, it then becomes protected by Family Educational Rights and Privacy Act (FERPA). |
| Individuals, Programs, Organizations (Page 2) |
Please list all entities allowed to exchange information. Include the referral source if appropriate to allow information to flow back to the source, especially if it is a primary healthcare provider. |
| EA rules citations |
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