CUA
The Catholic University Of America
Office of Disability Support Services
620 Michigan Ave NE, 201 Pryzbyla Center
Washington , DC 20064
202-319- 5211
Fax 202-319-5126
CONFIDENTIAL
CONSENT AND AUTHORIZATION TO RELEASE INFORMATION FROM DSS TO PARENTS
Pursuant to Federal Guidelines concerning my right to confidentiality, and state law concerning privileged communication; I _____________________hereby authorize Disability Support Services at The Catholic University of America
To release the following information from my file:
___ Diagnosis (generally used for physical/medical disabilities and/or conditions)
___ Psycho-educational Evaluation (generally used for ADD, ADHD and learning disabilities) or Psychological Evaluation
___ History of Accommodations used while at CUA
___ File status for DSS
___ Other: _____________________________________________________________
Purpose of disclosure:__________________________________________________________________
____________________________________________________________________________________
The information is to be released to:
Name: ______________________________________
Address: _______________________________________________________
City, State, Zip __________________________________________________
Phone: _____________________________
Relationship to student: Mother Father Legal Guardian Other: _________________
Date and time of contact: _________________________________
I understand that this authorization for confidential information applies only to the individual named above and only for the purpose stated above on the scheduled date and time and does not permit the release of information concerning me to any other individual or at any other time to the individual named above.
I understand that I may revoke this consent to release information at any time except for release of information that has already occurred. I also understand that any release made between the time I authorized it and then revoked it shall not constitute a breach of my right to confidentiality.
A photocopy or fax of this authorization shall be considered as effective and valid as the original.
Print Name: ________________________________ Signature: _________________________________
Date of Birth: ____________ ID #: ______________
________________________ ___________
DSS Staff/Witness Date
12/19/12