- Created 06/04
- Reviewed 04/22
To meet Federal and State requirements and provide ongoing care, parent/guardians or pregnant individuals will be requested to complete Parent/Guardian Permission to Reveal or Obtain Confidential Information (ROI) Form (ERSEA 1d) or Adult/Pregnant Individual Permission to Reveal or Obtain Confidential Information Form (ERSEA 1f). These could include but are not limited to: local school district, health care provider, dental provider, WIC provider, any specialist that have seen the child/family or agencies that are assisting the child/family. They will expire 18 months after signature date unless otherwise noted on the release form.
Completion of Parent/Guardian or Prenatal Permission to Reveal or Obtain Confidential Information for HS/EHS/ECEAP can happen during these timelines:
- At Intake Appointment prior to enrollment to the program.
- At the Welcome Visits, ROI’s are reviewed, updated and any additional are created based on need to meet State/Federal guidelines and provide ongoing care.
- Anytime throughout the school year as ongoing needs and/or providers of services change for a student, parent/guardian.
Placement of Parent/Guardian or Prenatal Permission to Reveal or Obtain Confidential Information form:
- When DST staff obtains the original ROI, they will place a copy in the red working file prior to sending the original to the Program Coordinator. The Program Coordinator database into the health module of ChildPlus.net; initial and date bottom right-hand corner of original ROI; scan and attach the original ROI into the enrollment module of ChildPlus.net; and send the original back to the DST.
- The copy will be shredded upon return of the original.
- The original is placed in the site file and documented on the Administration Site File Form.
Use of The Parent/Guardian or Prenatal Permission to Reveal or Obtain Confidential Information form:
- At the request of the parent/legal guardian and/or an appropriate staff member, staff will print a copy of the pertinent ROI from the database and attach to the request.
- The exchange of information is for the purpose of meeting Federal/State requirements supporting the ongoing care of the student.
Mental Health Releases at Intake, Welcome Visits and as needed:
- Parents/Guardians or Pregnant Individual will be invited to initial mental if they would like our mental health specialists or the child’s teacher to be able to coordinate care relating to mental health needs with the provider they are completing the ROI for (common places we coordinate with include the school district, primary care providers, occupational therapist, or a mental health agency).
- Records from Mental Health agencies will be requested with form MH 5b.
Exchange of Information:
- A Release of Information (ROI) form (ERSEA 1d), completed, signed and dated by the student’s parent/guardian or pregnant individual is required for the exchange of information to another agency.
- White out is not to be used on ROI’s under any circumstance. If a change needs to be made, a single line will be drawn through it with the original signature’s initials. (Applies to the parent portion and office for databasing.)
- If there are any crossed off items and there is information written over the crossed off information, complete a new ROI. If the parent has initialed by the written information then the ROI may be used.
- Include a note to office staff for reasons why there are duplicate or revised ROI’s being submitted to the office. In turn, office staff will include a note explaining why a ROI was returned so the staff know what action to take.
Revocation of Authorization of Release of Information:
- A person may revoke their authorization of the Release of Information (ERSEA 1e) at any time.
- Form is to be on yellow paper.
- The form must be completed in writing with the original databased and also placed in file. A copy is given to the person authorizing the revocation.
- The revocation is not effective if HS/EHS/ECEAP has already received the protected health/education/mental health or other information based on the authorization the individual signed previously.