Name: Relationship:
Email or FAX: __________________________
Other:
I wish to limit disclosure as follows:
Signature of student OR legal guardian/authorized person Date
State
University
DISABILITY
ACCOMMODATIONS
& SUPPORT SERVICES
CHANNEL
ISLANDS
Disability Accommodations & Support Services
One University Drive
Camarillo, CA 93012
Arroyo 210
Phone: 805-437-3331
Fax: 805-437-8529
AUTHORIZATION FOR RELEASE OF CONFIDENTIAL INFORMATION
Student Name: ____________________________________________________________________________________
Date of Birth: ___________________________________ Student ID: __________________________
I, hereby authorize staff at Disability Accommodations & Support Services (DASS) at California State University
Channel Islands (CI) to share and exchange information from my DASS records to:
Phone: ______________________________________________
Address: __________________________________________________________________________________________
Purpose of exchange of information and disclosure: _____________________________________________________
Disclosure shall be limited to the following types of information:
Appointment and testing attendance only
This information will be provided in the
following way(s):
Summary of accommodations
Unrestricted communication
Written Verbal
Email or FAX All of the above
By signing below, I acknowledge that I have read and understand this Authorization:
1. I understand that I have the right to review and receive a copy of my confidential records from DASS, including the
current Authorization form. I understand that I can request a copy of this form after I sign it.
2. I understand that, unless withdrawn, this authorization will expire 365 days from the date of signature. A photocopy
of this form will be considered as valid as the original.
3. I understand that I may revoke this authorization at any time by notifying DASS at the address indicated above, in
writing, and this authorization will cease to be effective on the date notified except to the extent that action has
already been taken in reliance upon it.
4. I fully comprehend the issues concerning privacy, confidentiality, and my right to forfeit signature of this
authorization form. I understand that if I authorize disclosure of confidential information to someone who is not
legally required to keep it confidential, it may no longer be protected by state or federal confidentiality laws.
5. I realize that my eligibility for services is not conditional upon my compliance with authorizing this form.
Rev. 9/15/17
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