> stream 0000013911 00000 n 0000008695 00000 n 0000001526 00000 n 0000007550 00000 n 0000013791 00000 n 0000003010 00000 n It is also messy, because two laws can apply to this information. Documents may be faxed to 413-775-1434, brought to the nurses in Health Records Office N348, left in a locked box in Admissions C103 or outside N348 or mailed to the Health Records office. If your high school has merged into another school, the new school often has copies of transcripts and you can send your request there. All MIT Medical services, including Covid Pass testing, will be closed 12/24–25 and 12/31–1/1 Urgent Care will remain open 12/26-30, 10 a.m.–4 p.m. Forms & Documents Email or phone. Below are documents and forms for registering for our services. 5/2019) school personnel health record (for use after offer of employment has been made) i. information school position offered Health Plan Enrollment Form (PDF) Complete this form if you want to purchase health insurance coverage for your spouse, same-sex domestic partner and/or dependent children 19 or under. Phone (617) 495-4414. 0000004742 00000 n The medical record information release (HIPAA), also known as the ‘Health Insurance Portability and Accountability Act’, is included in each person’s medical file.This document allows a patient to list the names of family members, friends, clergy, health care providers, or other third (3rd) parties to whom they wish to have made their medical information available. Beginning January 31, 2021, physical examinations for school are to be documented on the NYS Required Health Examination Form or an electronic health record equivalent form. Student Health Record Folder (1008) 1008 - Student Health Record Folder Size: 11 3/4" x 18" (8 1/2" folded) 100 per package White card stock folder Folds in half to create a folder with a tab at the top. 0000012948 00000 n Sign in to save Coord,Clinical Research I at University of Massachusetts Medical School. Learn more about Massachusetts Public Records Law “ An Act to Improve Public Records ,” went into effect January 1, 2017. HIPAA limits who your health care providers can share your medical information with, unless you give your permission in writing by filling out an Authorization for Release of Information form. ... or if you need copies of your records. The form must be printed and filled out then sent via mail or fax. 0000001714 00000 n ... Law School Clinic Pound Hall 1563 Massachusetts Avenue Cambridge, MA 02138. 0000015844 00000 n 0000008257 00000 n 0000018071 00000 n NEW SCHOOL HEALTH FORMS AND TEACHER’S HEALTH EXAMINATION CARD (CS FORM 86) Teachers' Health Examination Card (CS Form 86).xlsx. 0000007527 00000 n Map it. 0000027409 00000 n 0000006476 00000 n 0000003575 00000 n Share 0 Tweet 0 Share. 0000004783 00000 n They do not constitute a mandate nor imply liability should the school choose other options. A Maryland Immunization Certification form for newly enrolling students may be obtained from the local health department or from school personnel. Instructions for Completing the Universal Child Health Record (CH -14) Section 1 - Parent . The medical record information release (HIPAA), also known as the ‘Health Insurance Portability and Accountability Act’, is included in each person’s medical file.This document allows a patient to list the names of family members, friends, clergy, health care providers, or other third (3rd) parties to whom they wish to have made their medical information available. �C3�L��l)�Ԯ��wGI��n�04�)Rǻ#�~���w�y��+O��J`!W4��x: �vC�L@kɕ������w��^�Zޯ�n ������ʻμe� �m� �p�D�����L�\K�z� ��=~��x�8���N"&�����t�S��o�/�5��<2���- z��8e�D:R��=���_����O�(7_��_L�e:�+E�x/��d�5��~����#�7FD&��<8�Mi.GL��BꄨuD�&��y#�c5�Ղi��.�=��?�?�@����B������4���ެK?eE�ѣ�Z�Q�2ec(1��/$�qkW�5n�#`��j���hF�5VH���j�֨�E[����W�~K�1݈������ �Dc$��t��i. H��V�O�8�_��䡮�� ��N�IpH����W��S��&���w�NB�ڛ�>-�ө��7��q��o����zquA�$gg�.ɧ2��%'��O ��i�Q� Patient Information . Assumptions To ensure these guidelines work correctly, the following must be done: Student demographics data as well as their contacts are in … 0000014425 00000 n Mailing Address. • Immunizations: Please attach complete Massachusetts Immunization Certificate/record • Due to software differences, this form may be used as a template for other formats. Medical records include a patient’s medical history, pathology, radiology, lab reports and operative reports of treatments and medical services. ... Asthma Medication Administration Form (School Year 2020-2021) Arabic, Bengali, Chinese, English, French, Haitian Creole, Korean, Russian, Spanish, Urdu; For an Insurance Enrollment appointment or before your first Medical or Dental appointment please fill out the medical or dental registration packet for your patient(s) age range and the Records Release Consent form. 0000003743 00000 n of RS 15-1154) Title: Microsoft Word - health_record_form.doc Author: techcoord Created Date: 5/31/2005 11:27:51 AM Health service, and/or Hoosier Healthwise, and/or First Steps and/or Children’s Special Health Care Services upon presentation of this form, any records or information pertinent to the development and implementation of a plan for service to meet the medical, educational, developmental, social, and rehabilitative needs of the participant named on J:��t��2-�'�7�UO�h�%�!�c�����gz&�m_���m ���� �y,� ��z�����Hqć� ���!�Gu�(>u�8��d�{(�`��������������i�A="���ִs�q��d]�H-TU��e�����̏`��\.�6A����"�]�ûlGH�Kˌ��m^�_~'�*�N�v�f�u6&uL$c0T@PT[�Z!%a(��6 ���`���;O�i? trailer << /Size 891 /Info 847 0 R /Root 851 0 R /Prev 292235 /ID[<545212e706479d1d8d7a8587c25c2779>] >> startxref 0 %%EOF 851 0 obj << /Type /Catalog /Pages 849 0 R /Metadata 848 0 R /Outlines 21 0 R /OpenAction [ 853 0 R /XYZ null null null ] /PageMode /UseNone /PageLabels 846 0 R /StructTreeRoot 852 0 R /PieceInfo << /MarkedPDF << /LastModified (D:20051020131058)>> >> /LastModified (D:20051020131058) /MarkInfo << /Marked true /LetterspaceFlags 0 >> >> endobj 852 0 obj << /Type /StructTreeRoot /RoleMap 53 0 R /ClassMap 56 0 R /K 390 0 R /ParentTree 807 0 R /ParentTreeNextKey 3 >> endobj 889 0 obj << /S 136 /O 274 /L 290 /C 306 /Filter /FlateDecode /Length 890 0 R >> stream H�b```f``k``2b@(��������pR�}�?�(@�H�AM�i��F�� ��.�:�;��*N���G�a� �I@� b1���et@ �1Pj2�30�U��,"t�a��6 0000002793 00000 n Note to Examiner: Please give the family a completed or updated yellow California Immunization Record. For all records relating to private business, correspondence, or trade schools , please contact the Massachusetts Division of Professional Licensure, Office of Private Occupational Education, at (617) 727-5811 or visit the Division's website . For a larger image, click here. 0000056417 00000 n (Please Print) STATE OF HAWAI‘I, DEPARTMENT OF EDUCATION, FORM 14, RS 18-0811, March 2018 (Rev. Massachusetts School Health Record Massachusetts-School-Health-Record.pdf , 139.579 KB; (Last Modified on May 15, 2017) Address 70 Amvet Boulevard, North Attleborough, MA 02760 0000098371 00000 n To ensure the best health for you and all Clark students, you will need to have your doctor or other health care provider complete Graduate Immunization Record forms. 0000095452 00000 n Insurance Information Form (PDF) Complete this form so UHS can bill your insurance company for your care. Attached is a copy of DepEd School Health Record or SHD Form (1-5) enclosure to DepEd Order No. 0000004499 00000 n 0000001664 00000 n Access Your Immunization Records. 0000006454 00000 n ���#w1���{@� �#��� ��``� 2020 - 2021 Survey Form-CD-31 Standardized form used to report immunization status of Missouri Public, Private, Parochial and Parish school children. 0000009639 00000 n H�b``�```�����8m*6���X ����X$�>(.0b�e�Ϡ���U���Ɂ��c���D��� �m��F�g�G�?Z1��5�y�s8N�n#��> �� �� endstream endobj 47 0 obj 124 endobj 8 0 obj << /Type /Page /Parent 3 0 R /Resources 9 0 R /Contents [ 18 0 R 20 0 R 22 0 R 24 0 R 26 0 R 28 0 R 34 0 R 36 0 R ] /Rotate 90 /MediaBox [ 0 0 612 792 ] /CropBox [ 0 0 612 792 ] >> endobj 9 0 obj << /ProcSet [ /PDF /Text ] /Font << /TT2 14 0 R /TT3 10 0 R /TT5 11 0 R /TT7 32 0 R /TT9 30 0 R >> /ExtGState << /GS1 45 0 R >> /ColorSpace << /Cs6 16 0 R >> >> endobj 10 0 obj << /Type /Font /Subtype /Type0 /BaseFont /OCAPFK+SymbolMT /Encoding /Identity-H /DescendantFonts [ 43 0 R ] /ToUnicode 12 0 R >> endobj 11 0 obj << /Type /Font /Subtype /TrueType /FirstChar 32 /LastChar 121 /Widths [ 250 0 0 0 0 0 778 0 333 333 0 0 250 0 250 0 500 0 0 0 0 500 0 0 0 0 278 0 0 0 0 0 0 722 0 667 722 0 556 0 722 0 0 0 611 889 722 0 556 0 0 0 0 0 0 944 722 0 0 0 0 0 0 0 0 444 500 444 500 444 333 500 500 278 278 500 278 778 500 500 500 0 333 389 278 500 0 722 0 500 ] /Encoding /WinAnsiEncoding /BaseFont /OCAPHL+TimesNewRoman /FontDescriptor 15 0 R >> endobj 12 0 obj << /Filter /FlateDecode /Length 217 >> stream 0000011117 00000 n To obtain a copy of your dental record, you should submit a signed and dated Authorization to Disclose Dental Records Form (links to forms are located below). Getting your records changed. Please attach additional information as needed for the health and safety of the student. Worcester (/ ˈ w ʊ s t ər / WUUS-tər) is a city, and county seat of, Worcester County, Massachusetts, United States.Named after Worcester, Worcestershire, England, as of the 2010 Census the city's population was 181,045, making it the second-most populous city in New England after Boston. To obtain a transcript from a Boston public high school that is STILL OPERATING, please fill out a school Transcript Request Form and fax it directly to the school. 0000002039 00000 n Address. Medical Information Forms. The answer is important. Work Telephone . The forms posted here are valid in Massachusetts, when completed by a competent adult at least 18 years old. 0000009617 00000 n Title: Microsoft Word - health_record_form.doc Author: cobrien Created Date: 12/14/2004 4:25:16 PM The goal of the Massachusetts public K-12 education system is to prepare all students for success after high school. I. 0000001896 00000 n Street. Health professionals often receive requests from people who wish to access health records. The State of Massachusetts requires that all students at any college within the state show a complete record of immunity against communicable disease. medication order form is needed for each medication administered in school. If you are looking for records from a closed degree-granting school, contact the successor institution listed here. 0000070800 00000 n 0000003788 00000 n 0000006253 00000 n 0000008673 00000 n The student record shall consist of the transcript and the temporary record, including all information recording and computer tapes, microfilm, microfiche, or any other materials regardless of physical form or characteristics concerning a student that is organized on the basis of the student's name or in a way that such student may be individually identified, and that is kept by the public schools of the … These are available in English, Spanish, and Russian. While diligent efforts are made every day across the Executive Branch to respond to a large number of public record requests, this law provides standards that will improve our approach so as to reduce delays and costs that burden accessibility. 0000098597 00000 n Massachusetts law requires that college students have certain immunizations before coming to school, ... How to Submit Your Immunization Records. 0000006275 00000 n In some cases, no privacy law applies to the health records. 0000039660 00000 n DM NO. Find information on Massachusetts laws, bills, state budget, people, committees, educate and engage, events, redistricting. 0000005992 00000 n Prince George's County Public Schools Sasscer Administration Building 14201 School Lane Upper Marlboro, MD 20772 School Health Services is comprised of professional staff who collaborate with other Department of Public Health programs and the MA Department of Elementary and Secondary Education to provide ongoing school health service systems development and technical assistance to the Commonwealth's public school districts and nonpublic schools. %PDF-1.3 %���� 0000011139 00000 n Designed by school nurses and directors, our secure, easy-to-use web-based solution manages health forms, allergies, medications and illness/injury tracking for your school throughout the school year. 0000004263 00000 n H��Wks����_��:@&��/,���L�v2���줭��0$1�����ﹻ�I,e9�*���>�=��ǞL�Kvyϊ�+����r=9y3���~"�\U̔. 0000004813 00000 n 0000009786 00000 n SCHOOL PERSONNEL HEALTH RECORD . 0000003513 00000 n Massachusetts public school students are leading the nation in reading and math and are at the top internationally in reading, science, and math according to the national NAEP and international PISA assessments. 0000102592 00000 n 0000001184 00000 n Copies of immunization records may be obtained without cost by contacting the Director of Counseling and Health Services at health_services@wheatoncollege.edu. MASSACHUSETTS SCHOOL HEALTH RECORD Health Care Provider’s Examination ... (if relevant to the student’s health and safety) Please circle those administered in school; a separate medication order form is needed for each medication administered in school. 0000001171 00000 n �>Di��Cq����ⓔ����]�ǂp������=N��3�y��Y� M��p�A+���Ɗ��ޖ�z㈴C�7���%7�k trailer << /Size 48 /Info 4 0 R /Root 7 0 R /Prev 107208 /ID[<4b6d1428e160a480b73a726586c88021><0ddcf8a1b9c4aee07b31c12fe17a5c0d>] >> startxref 0 %%EOF 7 0 obj << /Type /Catalog /Pages 3 0 R /Metadata 5 0 R /PageLabels 2 0 R >> endobj 46 0 obj << /S 36 /L 137 /Filter /FlateDecode /Length 47 0 R >> stream 0000003015 00000 n Please circle those administered in school; a separate medication order form is needed for each medication administered in school. These sample resources may be modified for your use consistent with NYSED, local district policy, and school … The Health Records staff can remove the hold as soon as they receive valid documentation for the requirement. If The immunization certification form (DHMH 896) or a printed or a computer generated immunization record form and the required immunizations must be completed before a child may attend school. %PDF-1.3 %���� 6 0 obj << /Linearized 1 /O 8 /H [ 1273 236 ] /L 107454 /E 105624 /N 1 /T 107217 >> endobj xref 6 42 0000000016 00000 n 0000012375 00000 n 0000002502 00000 n Blood Lead Testing ... Standard Prescribers Order Form s for Specialized School Health Services; Contact. Health Forms for Parents and Prescribers School Health Health Forms for Parents and Prescribers. 0000010528 00000 n endstream endobj 13 0 obj << /Type /FontDescriptor /Ascent 891 /CapHeight 656 /Descent -216 /Flags 34 /FontBBox [ -558 -307 2034 1026 ] /FontName /OCAPFJ+TimesNewRoman,Bold /ItalicAngle 0 /StemV 160 /FontFile2 39 0 R >> endobj 14 0 obj << /Type /Font /Subtype /TrueType /FirstChar 32 /LastChar 146 /Widths [ 250 0 0 0 0 0 0 0 333 333 500 0 250 0 250 278 500 500 500 500 500 500 500 500 500 500 333 333 0 0 0 0 0 722 667 722 722 667 611 778 778 389 0 778 667 944 722 778 611 0 722 556 667 722 722 1000 0 722 667 0 0 0 0 500 0 500 556 444 556 444 333 500 556 278 0 556 278 833 556 500 556 0 444 389 333 556 500 722 0 500 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 333 333 ] /Encoding /WinAnsiEncoding /BaseFont /OCAPFJ+TimesNewRoman,Bold /FontDescriptor 13 0 R >> endobj 15 0 obj << /Type /FontDescriptor /Ascent 891 /CapHeight 0 /Descent -216 /Flags 34 /FontBBox [ -568 -307 2028 1007 ] /FontName /OCAPHL+TimesNewRoman /ItalicAngle 0 /StemV 0 /FontFile2 42 0 R >> endobj 16 0 obj [ /ICCBased 38 0 R ] endobj 17 0 obj 2326 endobj 18 0 obj << /Filter /FlateDecode /Length 17 0 R >> stream Although they won't need it for school, the four-part medical form from the Boy Scouts of America needs to be filled out by your pediatrician or other healthcare providers if your child is going to participate in a Scouting event. Please have the parent/guardian complete the top section and sign the consent for the child care provider/school nurse to discuss any information on this form with the health care provider. Given that schools may have sensitive health information — or request that information from students and parents — what law covers health record privacy for school records? Massachusetts School Record Form (RTF 123.91 KB) Massachusetts School Health Record/Physical Examination Form (PDF 12.5 KB) Massachusetts School Health Record/Physical Examination Form … Health Assessment Record To Parent or Guardian: In order to provide the best educat ional experience, school personnel must understand your child’ s health needs. 0000003827 00000 n On this page... 504 Accommodations Guidelines for the Provision of Health Services and/or Section 504 Accommodations. 0000011791 00000 n Please circle those administered in school; a separate medication order form is needed for each medication administered in school. Massachusetts is redesigning its district and school accountability system in 2018. ���y&��h>5��j)�Tl����Q,�{U�R~xqeV�l����*���˦b�ev9�[� Y�m� New School Health Forms.xlsx. H��W�o�6�_q/C)`�E��G��'�R [� School Health is the largest distributor of school nurse, sports medicine, special education, speech and health supplies to school nurses, athletic trainers and special education departments in the U.S. Missouri Statutes. 0000015866 00000 n HEALTH EXAMINATION IMMUNIZATION RECORD NOTE: All tests and evaluations except the blood lead test must be done after the child is 4 years and 3 months of age. If you think your health record is incorrect, you should let your GP or other health professional know and they will help you to update it. 0000012353 00000 n 0000014220 00000 n endstream endobj 864 0 obj << /Filter /FlateDecode /Length 231 >> stream Scouting Annual Health and Medical Record. May a school accept an electronic health exam form from a private healthcare provider? You can choose the option to encrypt the responses with JotForm to ensure the privacy of responses from our customers. The goal of the Massachusetts public K-12 education system is to prepare all students for success after high school. and are further protected by federal laws. RECENT MEMORANDA. )hp�ߓD�Qnݓ�*ӹ��##R g-1`�RP��Ar7r?��hM�yR9�7`&7GY��X�!�0��]$k�6F;�����l��������MU�r��VuE�������щ֫f���>�l&�u�.���-�������O�����KG�qSe3���r�|(� �O���m�b�[]X*m���ŐdyG[��s����U�����������3��>�Α���m����7ĈԷm]��:/~��hk���X� g�fp�z�T�9��q�����3������-���|�ڍ�z�Ns��l���q���О Please attach Massachusetts Immunization Information System . 0000002049 00000 n Please circle those administered in school; a separate medication order form is needed for each medication administered in school. 0000105684 00000 n Usual Source of Medical Care. Login to your account and click on "Immunizations." 0000001488 00000 n 0000004836 00000 n The WIC box needs to be checked only if this form is being 0000006298 00000 n H��V�n�8}��0��i�")iQHw�E���)-���*|Y��v��;CɺؒS��ѐ3�gn��e�IW%�.#g�VG�������3{̶i�ˢ��P们,��3�7�}tng�$$g��RA��y!$�A�TZ����g@�,�d��,�L�{�`b\;-K�Z}�������I^�z���-�bO�͡�U 0000024732 00000 n Health Forms and Notices. You can find school fax numbers on the school listings pages. MDPH 10/20/05 MASSACHUSETTS SCHOOL HEALTH RECORD Health Care Provider’s Examination Name _____ Male Female Date of Birth:_____ Health and care records are confidential so you can only access someone else's records if you're authorised to do so. MI Sex Date of Birth . ... Massachusetts Department of Public Health CERTIFICATE OF IMMUNIZATION Name: First. Physician’s Name. 0000012926 00000 n H�T�MO� ����9jȼ3����Sw�y���R0=&���KX� �qr�3i��mf�g�ߖ�s�� m��[N.�6��㍸�B��)+w��#+����P PENNSYLVANIA DEPARTMENT OF HEALTH . Welcome to the Auburn Public Schools, a public K-12 school district located in Auburn, MA. 0000056622 00000 n Although they won't need it for school, the four-part medical form from the Boy Scouts of America needs to be filled out by your pediatrician or other healthcare providers if your child is going to participate in a Scouting event. Social Security Number. Scouting Annual Health and Medical Record. When specifying the address for sending the health record specify complete information, including zip code and the office that it should be sent to, not just a street address, to ensure timely delivery to the recipient. [��(#�TCg��a6�P�zC��W���/]��2'�g��׍�"���R ڪ��X�QWk��=�~{>���0Ưw�_ �=����n�����~�q�����1_��V-���{��2�&�=�I�q)�kqQ_//�D��̨�.��|��Kxgo���˷/u��e拏�v�����Lړcs(G}ˇP�����. 33, s. 2019 dated December 09, 2019, from DepEd Secretary Leonor Magtolis Briones, DepEd-Central Office entitled “IMPLEMENTING GUIDELINES ON THE COMPREHENSIVE ORAL HEALTH PROGRAM OF THE DEPARTMENT OF EDUCATION”, the contents of which are self-explanatory, for information and strict … 374 S. 2020 – WORKSHOP ON CONTINGENCY PLANNING FORMULATION (EARTHQUAKE) Disclosure of Medical Information Authorization for Harvard University Health Services to release your medical records to the parties you specify. Health Care Provider’s Examination. 0000008235 00000 n 0000014605 00000 n 0000009808 00000 n The goal of the Massachusetts public K-12 education system is to prepare all students for success after high school. 0000059934 00000 n MASSACHUSETTS SCHOOL HEALTH RECORD . ӜQ��aZ�Ϙ��HGks��/p�4��忕Y��d@����j���â���i�M|W���]E����� �������`By>����Wg�8sr��y3[F�ᆷoo�ڱ�R%L�C;��(X�TI�i�B�Zk�2/�"s6]K��DpEs=��i�OL�Y��3$�TJ3i�,o��&Z�ϓ$�8Z������C���yt�x�Eۉw�YܞB{�S;Z�]:���Tӯn��CF�q@X��e�$r./���0y�o��5���D[ 6/2012) Page 1 of 4 Dental Exam: K/1 Bureau of Community Health Systems Division of School Health SCHOOL HEALTH RECORD NAME: LAST, FIRST, MIDDLE Massachusetts public health laws provide special confidentiality protections for certain health records. Massachusetts public school students are leading the nation in reading and math and are at the top internationally in reading, science, and math according to the national NAEP and international PISA assessments. ... University Health Services 150 Infirmary Way, UMass Amherst Amherst, MA 01003. Massachusetts Department of Public Health HIPAA (Health Insurance Portability and Accountability Act) is a federal law that protects the privacy of your medical records and information. Please have the parent/guardian complete the top section and sign the consent for the child care provider/school nurse to discuss any information on this form with the health care provider. 0000014627 00000 n 0000003849 00000 n Massachusetts Collaborative — Massachusetts Standard Form for Medication Prior Authorization Requests May 2016 (version 1.0) F. Patient Clinical Information *Please refer to plan-specific criteria for details related to required information. 0000013559 00000 n All forms must have a signature. � 9���?U�8�&f�:�^�zl�S�LCR��|&����H+ ��_���@>��)s� P\���s;D@� l�?g endstream endobj 890 0 obj 267 endobj 853 0 obj << /Type /Page /Parent 849 0 R /Resources << /ColorSpace << /CS0 860 0 R /CS1 861 0 R >> /ExtGState << /GS0 884 0 R /GS1 885 0 R >> /Font << /TT0 857 0 R /TT1 855 0 R /TT2 854 0 R /C2_0 865 0 R >> /ProcSet [ /PDF /Text ] >> /Contents [ 863 0 R 867 0 R 869 0 R 871 0 R 873 0 R 875 0 R 877 0 R 879 0 R ] /MediaBox [ 0 0 612 792 ] /CropBox [ 0 0 612 792 ] /Rotate 0 /StructParents 0 >> endobj 854 0 obj << /Type /Font /Subtype /TrueType /FirstChar 32 /LastChar 146 /Widths [ 250 0 0 0 0 0 0 278 333 333 0 0 250 333 250 278 0 0 0 0 0 0 0 0 0 0 333 0 0 0 0 0 0 722 667 722 722 667 611 0 778 389 0 0 667 944 722 778 611 0 722 556 667 722 722 0 0 722 0 0 0 0 0 500 0 500 556 444 556 444 333 500 556 278 333 556 278 833 556 500 556 0 444 389 333 556 500 722 500 500 444 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 333 ] /Encoding /WinAnsiEncoding /BaseFont /LCALPL+TimesNewRoman,Bold /FontDescriptor 858 0 R >> endobj 855 0 obj << /Type /Font /Subtype /TrueType /FirstChar 32 /LastChar 122 /Widths [ 250 0 0 0 0 833 0 0 333 333 500 0 250 333 250 278 0 500 500 500 500 500 500 500 0 0 278 278 0 0 0 0 0 722 667 667 722 611 556 722 722 333 0 722 611 889 722 722 556 0 667 556 611 0 722 944 0 722 611 0 0 0 0 500 0 444 500 444 500 444 333 500 500 278 0 500 278 778 500 500 500 0 333 389 278 500 500 722 500 500 444 ] /Encoding /WinAnsiEncoding /BaseFont /LCALNJ+TimesNewRoman /FontDescriptor 856 0 R >> endobj 856 0 obj << /Type /FontDescriptor /Ascent 891 /CapHeight 656 /Descent -216 /Flags 34 /FontBBox [ -568 -307 2028 1007 ] /FontName /LCALNJ+TimesNewRoman /ItalicAngle 0 /StemV 94 /XHeight 0 /FontFile2 882 0 R >> endobj 857 0 obj << /Type /Font /Subtype /TrueType /FirstChar 32 /LastChar 146 /Widths [ 250 0 0 0 0 0 0 0 333 333 0 0 250 333 250 278 500 500 500 0 0 500 0 0 0 0 333 333 0 675 0 0 0 0 0 667 722 611 0 0 722 333 0 0 0 833 667 0 611 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 500 500 444 500 444 278 0 500 278 0 444 278 722 500 500 500 0 389 389 278 500 444 667 444 444 389 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 333 ] /Encoding /WinAnsiEncoding /BaseFont /LCALLI+TimesNewRoman,Italic /FontDescriptor 859 0 R >> endobj 858 0 obj << /Type /FontDescriptor /Ascent 891 /CapHeight 656 /Descent -216 /Flags 34 /FontBBox [ -558 -307 2034 1026 ] /FontName /LCALPL+TimesNewRoman,Bold /ItalicAngle 0 /StemV 160 /XHeight 0 /FontFile2 880 0 R >> endobj 859 0 obj << /Type /FontDescriptor /Ascent 891 /CapHeight 0 /Descent -216 /Flags 98 /FontBBox [ -498 -307 1120 1023 ] /FontName /LCALLI+TimesNewRoman,Italic /ItalicAngle -15 /StemV 83.31799 /XHeight 0 /FontFile2 881 0 R >> endobj 860 0 obj [ /ICCBased 886 0 R ] endobj 861 0 obj /DeviceGray endobj 862 0 obj 1076 endobj 863 0 obj << /Filter /FlateDecode /Length 862 0 R >> stream These requests can include requests from patients to view or obtain copies of their own health record using GDPR subject access request rights or the requests might come from third parties, such as the police. Certificate of Immunization Massachusetts Department of Public Health 7-08 . Instructions for Completing the Universal Child Health Record (CH -14) Section 1 - Parent . 0000105516 00000 n 0000001509 00000 n City State Zip . Dental records can include medical history, pathology, radiology, lab reports, and other sensitive information such as genetic testing, sexually transmitted diseases, and HIV test results, etc. 0000001273 00000 n Last Name. 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