NORTHAMPTON COUNTY PUBLIC SCHOOLS
Office of Special Programs
7207 Young St.         Machipongo, VA 23405
757-678-5151 Phone    757-678-7267 Fax

SPECIAL EDUCATION PROGRAMS INFORMATION RELEASE
						
Student		DOB		Date		
Medicaid #		SS#		

❒  I DO GIVE PERMISSION	 ❒ I DO NOT GIVE PERMISSION  
for the release of any information (medical, scholastic, sociological, economic, educational, psychological, psychiatric  evaluations, discharge summaries, special education  eligibility minutes, current IEP, and special education eligibility assessment reports) regarding my child between the Northampton County Public Schools and the following agencies for the purpose of determining appropriate educational and / or medical services.  PLEASE CHECK ALL THAT APPLY.	
			
	______ Accomack County and Northampton County Department of Social Services
	______ Accomack and Northampton County Public Health Department
	______ Bayview Community Health Center _______________________________ Physicians Name
	______CHKD __________________________________________ Physicians Name
	______ Disability Determination Services
	______ Dominion Psychiatric Associates _________________________ Physicians Name
	______Eastern Shore Community Services Board _______________________ Case Workers Name
	______ Franktown Community Health Center _________________________ Physicians Name
	______ Northampton County Department of Social Services
	______ Northampton County Juvenile Court Services
	______Riverside Cape Charles Medical Center __________________ Physicians Name
`	______ Riverside Eastern Shore Physicians & Surgeons ______________________ Physicians Name
	______ Riverside Shore Memorial Hospital 
	______ Private School/ Agency Name __________________________________________________
	______ Other: ______________________________________________________________________________________________

PRIMARY CARE PHYSICIAN (PCP)                                                                                                               

_______________________________________________  	 ____________/_________/_________
 Signature of Parent, Guardian or Surrogate     		 		       Month            Day          Year	

                                                                                                	___________/_________/__________
 Signature of Child if 14 yrs of age or older       		 		        Month            Day          Year

THIS PERMISSION SHALL REMAIN VALID FOR ONE FULL CALENDAR YEAR FROM 
THE DATE OF SIGNATURE UNLESS OTHERWISE NOTED.

THIS PERMISSION SHALL INCLUDE VERBAL REPORTS, ELECTRONIC TRANSFER REPORTS AND/OR DISCLOSURE AND DISCUSSION OF RECORD CONTENTS VIA TELEPHONE.

ATTENTION: YOUR PHOTOCOPIED OR FAXED SIGNATURE WILL BE AS VALID AS YOUR
                                    ORIGINAL SIGNATURE ON THIS ORIGINAL DOCUMENT