Authorization for Release and Exchange of Information
I, ____
__________________________________ do hereby authorize the release and exchange of the following information:
1. Documentation of disability and recommendations for reasonable accommodations.
2.
Between
the following individuals and/or agencies:
Name:
Title:
Business/Agency:
Address:
City/State/Zip:
Phone:
Fax:
AND
Johnna Antonich: Accessibility Services Coordinator
Montana State University—Northern
P.O. Box 7751
Havre, MT 59501
(406) 265-3555
(406) 265-3508 fax
I understand
that all information released and/or exchanged is confidential and may not be released to any party
other than those listed above without my written consent. I also understand that I may cancel this agreement at
any time by notifying either party listed above in person or in writing.
Signature:_
_____________________________________ Date: _________________
Name
(Printed): ________________________________________________________
Address
: ________________________________________________________________
City/St
ate/Zip: _________________________________________________________
Phone: _
________________________________________________________________
This authorization will expire two years from the date signed, unless otherwise noted here: ________________
