Caldwell public schools

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Dear Parent,
HIPPA (Health Insurance Portability and Accountability Act) allows the schools, doctor's offices and health departments to exchange information regarding a student's immunization status without signed parental consent. We have been informed that FERPA (Family Educational Rights and Privacy Act) over rides HIPPA and immunization information on a student cannot be released from the school without a parent/guardian signing an " Authorization for Release of Health Care Information" form. This form is for immunization information only. No other medical information. When you sign the attached form you will be allowing the school permission to provide your child's physicians, the health department and the Kansas Immunization Registry (explained below) immunization history on your child if requested. You will need to indicate on the form where the information can be released.

The Kansas State Dept. of Health and Environment operates the Kansas Immunization Registry (KSWebIZ) which is a web-based centralized birth to death database that will maintain statewide immunization records. This process will involve county health departments, physicians and schools. Security measures are in compliance with HIPPA and Kansas confidentiality statues. KDHE has stringent security measures for accessing the Kansas immunization Registry.

The goal of the registry is to maintain immunization records that are accurate, up-to-date and complete-with all demographic and vaccination information pertaining to each individual consolidated into one non-duplicative history. This internet accessible system enables end users, to accurately assess a student's immunization status.

These are some of the benefits of KSWebIZ:

  1. Consolidates and combines immunization information from a multitude of sources into a single record stored in one place.

  2. Provides an accurate and official copy of a child's immunization history for daycare, school, camp, college, etc.

3.. Accurately tracks the ability to ensure that a child is current and protected from preventable diseases.

  1. Reminds families and providers when immunizations are due or if one has been missed.

  2. KSWebIZ will help providers and parents determine when immunizations are due thereby preventing duplicate or unnecessary vaccinations.

  3. Allows the school nurse to view a student's vaccination history, add histories that may be missing, print electronic immunization cards and Kansas Certificate of Immunizations.

Attached is the "Authorization for Release of Health Care Information" form that you will need to sign and return for immunization information to be shared with your child's physician, the health department and the Kansas Immunization Registry. You need to indicate where the information can be released.



School: Caldwell Public Schools, U.S.D. #360

Name of Student:__________________________________________ Grade_______


Phone:____________________________ Date of Birth:______________________

Name of Parent or Guardian: ___________________________________________
Relationship to Student:____________________________________________

Address (if different than above):

Phone (if different than above):

I hereby authorize CALDWELL PUBLIC SCHOOLS, USD #360 to release immunization information in his/her/their possession relating to the above-named Student to:

______________________________ County Health Department

______________________________ (Health Provider/Physician)

(USD / School Official)

Kansas Immunization Registry (Immunization information disclosed to

the Kansas Immunization Registry will be used for purposes of assessment and reporting to prevent disease.)

I affirm that I am authorized to consent to release of medical information on behalf of the Student. I understand that this authorization will expire when the Student is no longer enrolled in the above-named school and that I may revoke this authorization in writing at any time.

Parent / Guardian Signature:____________________________________


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