Consent for Release of Confidential Information Form
Student Name: Student ID: Date of Birth:
Address:
Phone:
On-Campus Provider: Student Health Center Counseling Center
Name of On-Campus Provider:
Off-Campus Provider:
Address:
Phone: Fax:
Recipient: Office of Disability Services or Other:
Address:
Phone: Fax:
Information: All professional, medical, counseling, mental and physical health, and other information or records,
confidential or otherwise pertaining to me, my evaluation, or treatment.
Reason: To assist in evaluating my request for reasonable accommodations and to ensure the appropriate provision of
disability services at Texas State University.
Consent: I consent to the release of the Information to the Recipient described above for the Reason shown above. I
authorize and request that the Provider furnish the Information as soon as it is practical to do so.
Release: I release and discharge the Provider and the Recipient from any claims that I may have as a result of providing
the Information to the Recipient under this Consent. I understand that I cannot sue or recover anything from the Provider
or Recipient as a result of providing this Information.
Revocation: I understand that I can revoke this Consent only by giving written notice of revocation to both the
provider and the Office of Disability Services at Texas State University.
Student Signature:
Date:
Please return the completed form to the Office of Disability Services via in person or email at ods@txstate.edu. If you
have any questions, feel free to contact our office. Thank you.
OFFICE OF DISABILITY SERVICES
601 University Drive | LBJ Student Center 5-5.1 | San Marcos, Texas
78666-4616
phone: 512.245.3451| fax: 512.245.3452 |
WWW.ODS.TXSTATE.EDU
This letter is an electronic communication from Texas State
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