Ronald McDonald Children’s Hospital of
This is to authorize  Loyola University Medical Center                             
                         (name of institution holding medical     (Home School)
                          records/data)

                         Ronald McDonald Children’s Hospital of
to release               Loyola University Medical Center                          
                         (name of institution, physician, person  (Home School)
                          to receive medical records (data)

the following medical data: _______________________________________________________
                                        Patient’s Name               Birthdate

                            _______________________________________________________
                                        Patient’s Address

Dates of Treatment:         _______________________________________________________

___ Out-Patient Records
___ Discharge Summary
___ X-ray Reports
___ Special Procedure Reports    Neuropsychological evaluation if ordered          

    _______________________________________________________________________________

___ Other as Specified:    Diagnosis, hospital education plan, school progress     

    notes, case study evaluation(s) and EIP(s), home school classes and            

    performance.                                                                   

Purpose of need for release of this information (optional for data other than 
psychiatric records)

       To coordinate the hospital school program                                   

    _______________________________________________________________________________

This authorization includes permission for the institution/person names above to 
view and/or copy the data specified. The authorization is valid for ________ days 
from the date of signature; it will be honored for 90 days unless otherwise 
specified.

The person authorizing the release of this information has the right to inspect 
the data prior to its release, and the right to revoke consent at any time.

     ___________________________________________   _______________________________ 
       Signature of Patient or Legal Qualified	                Witness*
        Representative (indicate relationship)

     ___________________________________________   _______________________________ 
               Date of Signature                                Witness