RELEASE of INFORMATION AUTHORIZATION
Name:
UM ID:!!
Date!of!Birth:
Address:
Phone:
!!!!!
UM Email Address:
I authorize Disability Services for Students at the University of Montana to (Check the appropriate box below):
Receive&my&protected&information&from&the&following&location:
Or&
Release&my&protected&information&to&the&following&location:&
Name:
Agency Name:
Address:
Phone:
Fax:
Purpose of the Disclosure (Check the appropriate box below):
Disability documentation/Verification for Disability Services for Students’ eligibility
Service coordination
My personal records
Other
I understand that my records may contain information regarding the diagnosis or treatment of HIV/AIDS, sexually
transmitted disease, drug and/or alcohol abuse, mental illness, or psychiatric treatment. I give my specific
authorization for these records to be released.
Type of Information to Be Received/Released-Other Request or Limitation
Medical Records
Psychiatric/Psychological Diagnostic Reports (i.e. ADHD, Learning Disability, Mental Illness, etc.)
Psychiatric/Psychological Treatment or Progress Notes
Drug/Alcohol abuse/treatment and diagnosis
Sexually transmitted disease
HIV/AIDS diagnosis/treatment
Academic Information
Other request or limitation (specify)
I understand that this authorization may be revoked by me at any time, provided that I do so in writing and submit it
to Disability Services for Students, up to the extent that the disclosure has not already been made prior to
revocation. Authorization will expire in 6 months unless otherwise specified. Expiration Date:
Signature:
Date:
Disability Services for Students | 154 Lommasson |University of Montana |Missoula, MT 59812|P: 406.243.2243|F: 406.243.5330
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