CONSENT FOR USE OR DISCLOSURE OF HEALTH INFORMATION BETWEEN REFERRAL PROVIDERS AND THE WISCONSIN BIRTH TO 3 PROGRAM

Parental Consent is not required by the Wisconsin Birth to 3 Program to receive a referral; however the parent or legal guardian of the child must provide consent for screening, evaluation, and enrollment into the Birth to 3 Program and for disclosure of records. Foster parents do not have presumed legal rights to provide parental consent. The consent for release of information on this form authorizes the disclosure and/or use of the child’s health or developmental information between the referring provider and the county Birth to 3 Program as identified on the referral form.

I have the following rights with respect to this consent:

• You are not required to sign this authorization. Except permitted under applicable law, refusal to sign will not effect treatment, enrollment, or benefits eligibility.
• You may revoke this consent, in writing, any time except for information already released as a result of this authorization. The written revocation must be given to the organization authorized to release the information.
• You have the right to inspect and, upon paying applicable fees, obtain a copy of the disclosed records.
• The information that you authorize to be released may be redisclosed by the recipient of these records only if allowed by law. If information is redisclosed, the recipient of the redisclosed information may be controlled by different laws.

Your child might be seen by other professionals who monitor your child’s overall growth and development. Your child’s health care provider sees your child at well-child visits and for medical treatment. Your child care provider sees your child interact with other children every day. Sometimes your child’s health care and other service providers may need more information, like evaluation by other specialists, the best care for your child. The county Birth to 3 Program can be a resource to help identify your child’s needs. The primary goal of this consent form is to allow communication between your child’s health care and other service providers and the county Birth to 3 Program so these providers can work together to help your child. 

This consent form was developed to ensure compliance with the federal and state laws regarding the protection of medical and educational information. This consent includes the sharing of information as authorized under federal/state confidentiality laws, Health Insurance Portability and Accountability Act (HIPAA) Privacy Regulations and Family Educational Rights and Privacy Act (FERPA) guidelines. The purpose of the consent is to provide the county Birth to 3 Program with information to assist in the determination of the child’s eligibility for early intervention services as well to ensure the child’s health care provider receives information regarding the status of the child in the Birth to 3 Program. By authorizing the county Birth to 3 Program to share pertinent information, you help to ensure that your health care and other service providers remain an active participant in your child’s growth and development.

This consent form will follow your child’s referral to the county Birth to 3 Program as he/she is screened and/or evaluated to determine eligibility for the Birth to 3 Program. The information generated by this referral will become a part of the child’s educational record. The county Birth to 3 Program will protect this information as prescribed by HIPAA, FERPA, and other federal/state confidentiality laws.

Family Educational Rights and Privacy Act (FERPA) 34 CFR 99.30

Health Insurance Portability and Accountability Act (HIPAA) Privacy Regulations 45 CFR 164