Fillable DSS ReleaseInformation DSS Authorization and Request for Release of Information

Fill Online, Printable, Fillable, Blank DSS ReleaseInformation DSS Authorization and Request for Release of Information Form

Use Fill to complete blank online LARAMIE COUNTY COMMUNITY COLLEGE pdf forms for free. Once completed you can sign your fillable form or send for signing. All forms are printable and downloadable.

DSS ReleaseInformation DSS Authorization and Request for Release of Information

On average this form takes 2 minutes to complete

The DSS ReleaseInformation DSS Authorization and Request for Release of Information form is 1 page long and contains:

  • 0 signatures
  • 0 check-boxes
  • 6 other fields

Country of origin: US
File type: PDF

U.S.A. forms for Laramie County Community College

BROWSE LARAMIE COUNTY COMMUNITY COLLEGE FORMS

Related forms
Fill has a huge library of thousands of forms all set up to be filled in easily and signed.
Fill in your chosen form
Sign the form using our drawing tool
Send to someone else to fill in and sign.
find another form
 
TM
Disability Support Services
LARAMIE COUNTY COMMUNITY COLLEGE
1400 East College Drive
Cheyenne, Wyoming 82007
307.778.1359 • Fax 307.778.1262
Authorizaon and Request for Release of Informaon
To:
Re:
This is to authorize you to communicate with the Disability Support Services oce and
request you to furnish records, informaon, or opinions regarding the physical and
mental condion of this paent/student to the Disability Support Services (DSS) of
LCCC. Please include the following informaon:
• a diagnosis of the student’s current disability
• date of diagnosis
• how the diagnosis was reached
• the credenals of the professional
• how the disability aects a major life acvity
• how the disability aects the student’s academic performance
This release is given by the undersigned paent/student. Your full cooperaon in this
request is respecully requested.
You are further instructed not to disclose informaon to any other person without
wrien authority from paent/student to do so (pursuant to privilege and condenal
communicaons statutes).
Dated this day of , .
____________________________________
Printed Name
____________________________________
Signature
Please send records to the Disability Support Services
You may contact the DSS at 307.778.1359
13372 PRS 6/12
PRINT
Download
Save PDF to desktop
Email
Email completed PDF
Send for Signing
Email for others to sign
Print
Print document
Choose a Field
Click on a field and
select the person that should complete it
Want to add a signature?
You can add a signature field
and assign it to someone else
to sign
Choose a Field
Click on a field and
select the person that should complete it

DSS ReleaseInformation DSS Authorization and Request for Release of Information

This document is locked as it has been sent for signing.

You have successfully completed this document.

Other parties need to complete fields in the document. You will recieve an email notification when the document has been completed by all parties.

This document has been signed by all parties.

Completed 15 February 2020

Message

View Audit Log
Print With Audit Log
Duplicate Document