Consent And Authorization To Release Information

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