Fillable CONSENT FOR RELEASE OF CONFIDENTIAL INFORMATION (Big Bend Community College)

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CONSENT FOR RELEASE OF CONFIDENTIAL INFORMATION (Big Bend Community College)

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CONSENT FOR RELEASE OF CONFIDENTIAL INFORMATION
Disability Support Services (DSS)
TO:
Name of Agency/School
Address
City/State/Zip Code
FROM:
Student Name
Address
City/State/Zip Code
Date of Birth
You are hereby authorized to release pertinent medical, psychological, social or educational
information that the following agency and/or person may request about me. Send information
to:
Disability Support Services
Big Bend Community College
7662 Chanute Street NE.
Moses Lake, WA 98837
Phone: 509.793.2027
TDD: 509.793.2325
FAX: 509.762.3648
Information Requested:
This information will be used only as an aid in providing educational support services for which I
have applied.
The requesting agency/person has the responsibility of keeping this information confidential and
will not release this information to any other agency or person without my written consent.
Student Signature Date
Revised 6/4/18
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CONSENT FOR RELEASE OF CONFIDENTIAL INFORMATION (Big Bend Community College)

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Completed 4 February 2021

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