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Authorization for Release/Exchange of Confidential Information

About this Form

Form number: 336-32

Audience:  Parents/Guardians, School Staff

Last revised: March 2017

PART I: RELEASE OF RECORDS INFORMATION: In cases where it appears helpful to obtain non-Montgomery County Public Schools (MCPS) records or to share MCPS information with community resources because the information may reduce the need for testing or facilitate service provision, enter the title of the record(s) or the type of information to be shared, and the agency/person who has the information. Explain that the parent(s)/guardian(s)/eligible student’s signature authorizes MCPS to obtain the specified records and/or to share information with the specified sources, e.g., authorized health care provider, tutor who may be working with the student. See MCPS Regulation JOA-RA, Student Records, for additional details.

PART II: CONSENT FOR PARTICIPATING AGENCY TO BE INVITED TO IEP TEAM MEETINGS: Obtain the consent of a parent/guardian/eligible student for a participating agency such as the Division of Rehabilitation Services, or the Behavioral Health Administration, to be invited to attend any IEP team meeting at which transition services will be considered for a student with a disability. Inviting an agency representative does not guarantee attendance at an IEP meeting. 

PART III: PERMISSION FOR REFERRALS: Obtain the consent of a parent/guardian/eligible student for the student prior to making a referral for a high school student to a participating agency for transition services such as the Division of Rehabilitation Services, or the Behavioral Health Administration for the service(s) marked on the form.

Adobe PDF Authorization for Release/Exchange of Confidential Information76 KEnglish
Adobe PDF Autorización para Divulgación/Intercambio de Información Confidencial44 KSpanish
Adobe PDF Autorisation Pour la Divulgation d’Informations Confidentielles44 KFrench
Adobe PDF Giấy Cho Phép Phổ Biến/Trao Đổi Thông Tin Kín179 KVietnamese
Adobe PDF 授權披露/交換保密資料224 KChinese
Adobe PDF 비밀이 보장된 개인 정보의 제공 및 공유 허가서82 KKorean
Adobe PDF ምስጥራዊ መረጃ የመስጠት/የመለዋወጥ ፈቃድ የልዩ ትምህርት ጽ/ቤት65 KAmharic

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