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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: September 2018

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, Developmental Disability Administration (DDA), Department of Labor, Licensing, and Regulation (DLLR), 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 OR APPLICATION: Obtain the consent of a parent/guardian/eligible student prior to making a referral, and/or support with an application, for a high school student to a participating agency for transition services such as the Division of Rehabilitation Services, DDA, DLLR, or the Behavioral Health Administration for the service(s) marked below.

Adobe PDF Authorization for Release/Exchange of Confidential Information461 KEnglish
Adobe PDF Autorización para Divulgación/Intercambio de Información Confidencial44 KSpanish
Adobe PDF Autorisation Pour la Divulgation d’Informations Confidentielles44 KFrench
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