AUTHORIZATION FOR RELEASE OF INFORMATION FORM
The authorized parent or guardian gives permission to The Katallasso Group's (Truancy Prevention Program) to exchange, release, disclose, or obtain information and/or copies of all reports, records, and documents about themselves and their student receiving services within, to, or from the The Katallasso Group and their child's school district or other pertinent providers.
Purpose of Release: Acceptance for services at The Katallasso Group.
I understand that my records are protected under the Minnesota Government Data Practices Act, Minnesota Statutes, Chapter 13, and cannot be disclosed without my written consent or unless otherwise provided by law.
I understand that the information disclosed to the recipient(s) may no longer be protected by the privacy rules and may be subject to re-disclosure. After release to The Katallasso Group, the data may be defined as Court Services Data (Minnesota Statutes Section 13.84, subd. 1) and/or Corrections and Detention Data (Minnesota Statutes, Section 13.85, subd. 2) and, as a result, may be classified as either public, private or confidential data as defined by the provisions of Minnesota Statutes, Section 13.02.
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I also understand that I may revoke this consent at any time except to the extent that action has been taken in reliance on it (e.g., probation, parole, supervised release, work release, etc.) I also understand that if I do revoke this consent before the expiration date, the revocation must be made in writing by me and delivered to the agency listed above. This consent automatically expires upon discharge from supervision or one year from the most recent update shown below, whichever comes first. I also understand that I may not sign this authorization to release information, and the consequence has been explained to me.
