HIPAA Sample Letter
(Health Insurance Portability & Accountability Act Privacy Rule)
**Please revise according to your child's needs.
Dear Teacher (name),
I (name) give permission for all faculty and staff members to be advised of my child's (name) food allergies. The only food and/or beverages he/she can have must come from my home and sent into school with him/her. My child must not be allowed to consume any outside food or beverages thus causing him/her to go into Anaphylactic Shock which is life threatening.
The following is a list of ingredients my child is allergic to and CANNOT have in any form:
cc: School Nurse (name) and Principal (name)
Disclaimer: The information contained herein is not intended or implied to be a substitute for professional medical/legal advice. Please seek the advice of your physician regarding any treatment for allergies and asthma.