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:


Parent/Guardian Name

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.
Does your child have
severe food allergies?
You've come to
the right place.
Did you know?
* HIPAA was adopted in 2003

* Intent is to protect individuals' rights to control access and disclosure of private information

* Lets participatant know who will get information about their participation in research

Source: FAAN