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Release of Information


In accordance with Performance Standard 1304.20 (a)(1)(ii)(c): Written consent from the parent/guardian of a participant will be completed in order to obtain or exchange pertinent health information for the provision of health services, or to ensure a participant’s health needs are met.


  1. At enrollment, staff will determine the health and dental status of each participant.
  2. If the participant has a specific medical condition, staff will obtain Release of Information for any pertinent ongoing medical condition that may require special accommodation in the center or if documentation is needed for preventative services. Staff will also obtain pertinent ROI’s for a vision and or hearing specialist if the child wears glasses or the parent indicates the child is being followed for hearing concerns or has tubes.
  3. Health services staff may require additional ROI’s be obtained throughout the program year as needed for specific records to case manage a child’s health care needs, or to share classroom health observations with a health care provider.
  4. The Family Advocate (FA)/Teacher/Home Visitor will obtain the correct provider name and clinic name to request the records from and record this in Section 2 on the ROI.  Staff will record the correct address and spelling of provider name. This may need to be researched ahead of time with parent or through available resources. Staff must record this information on the ROI prior or while presenting to the parent for signature.
  5. Staff is not to send ROIs in to the central office for processing without the provider/clinic name and address clearly printed or it will be returned and cause delay in services for the participant.
  6. Staff will record the participant’s legal name, the name the child goes by at the center and any other names the child has obtained medical or dental care under on the appropriate lines. Staff will record the child’s correct date of birth on the appropriate line.
  7. Staff will review the ROI with the parent and request they sign and date.  Staff will then sign and date as the witness.
  8. Staff will give the pink copy of the NCR ROI to the parent, file the yellow copy in center file and send the white copy of the ROI to the Administrative Assistant at the central office for processing.
    1. ROI is faxed to appropriate provider and the date of fax is entered into ChildPlus as “ROI sent” as a Health Communication event by the Administrative Assistant.
    2. Health, Dental, Hearing, and Vision ROI’s are tracked weekly by the Administrative Assistant to ensure prompt receipt of needed records and will contact providers and/or re-fax if two weeks has passed without receipt of records.
    3. Once medical records are received at the central office, the status in ChildPlus is changed by the Administrative Assistant, relevant copies will be scanned into ChildPlus for viewing or printing, and appropriate data will be entered by the Administrative Assistant into ChildPlus.
    4. Appropriate service area will contact providers directly if the records are not received within three weeks of ROI fax date.
  9. Staff should reference ChildPlus to track the progress of the ROI’s sent to the central office.
  10. Staff should NEVER ask a parent to sign a blank ROI for any reason.
  11. Center Managers/FA must have prior permission to fax an ROI from the Health and Safety Manager.  Once faxed, be sure to use the “faxed” stamp on the top of the ROI so the CO knows that it has already been faxed.

Forms and Additional Guidance:

This policy complies with the following

Head Start Program Performance Standard:    1303.22
ODJFS Child Care Manual:    
CACFP Regulation:    
Caring for Our Children:    
Other Sources:    


Effective Date:   8/7/2017 Reviewed Date:   10/30/20, 6/16/22
Approved By Policy Council:   8/7/2017 Revision Approved By Policy Council:    
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