I am this child’s parent/legal guardian or educational decision maker and I wish to complete this section.
Please check all check boxes below if you are a parent and above check box is checked.

Please read and then initial all boxes to indicate that you understand your rights before signing. If you have any questions about your rights, please call Strong Start at (202) 727-3665. You may submit this referral without completing this section.

I understand that signing this authorization is not a condition of receiving future medical treatment or early intervention services.
I understand that I may revoke (i.e., cancel) this authorization at any time by notifying Strong Start in writing, and that any information shared prior to revoking this authorization will not be affected by a revocation.
I understand that before any specific services for my child are provided, I also have a right to authorize or decline those services.
I understand that feedback regarding this referral, including developmental and educational information about my child, may be provided to the referring professional in order to facilitate appropriate coordination of services.
I understand that if my child is Medicaid eligible and covered under EPSDT (early periodic screening diagnosis and treatment), this referral will be shared with my Medicaid Managed Care Case Manager / Service Coordinator.
I understand that once released, my information may be disclosed and may no longer be protected under the Health Insurance Portability and Accountability Act (HIPAA), but will not be re-disclosed by the DC Early Intervention Program in accordance with the Family Educational Rights and Privacy Act (FERPA). For more information, see 45 CFR (Code of Federal Regulations) 164.508 for HIPAA and 34 CFR Part 99 for FERPA.
I understand that this consent will expire in one (1) year and that a new consent form will need to be completed should my child continue to be eligible for Strong Start.