Legal name of child or special needs adult: First Last Place of birth Street Address City State / Province / Region ZIP / Postal Code Date of birth MM slash DD slash YYYY Authorization:I the parent or legal guardian of the above name individual authorize the disclosure of specified health records outlining the special needs or medical diagnoses to authorized individuals employed or affiliated with the Harrisville Police Department (HPD) and North View Fire District (NVFD). I understand that, if the persons or organizations I authorize to receive and/or use medical records are not subject to the federal or state health information privacy laws, they may further disclose the medical records in direct performance of their duties associated within the intent of HPD’s Venerable Adult & Special Needs Child Registry, in which case, it may no longer be protected by the health information privacy laws. This authorization is valid for one calendar year and will expire one year after the date listed with my signature below. I understand that I may revoke this authorization at any time by submitting written notice of the withdrawal of my consent to: police@harrisvillecity.gov I recognize that these records, once received by the department, may not be protected by the HIPAA Privacy Rule, but will become private records protected by HPD policy and the Department of Justice “No Disclosure Without Consent” (5 U.S.C. § 552a(b)) and become part of the database maintained by HPD.Name of Parent or Guardian First Last Date MM slash DD slash YYYY Signature Δ
