Fillable Release of Information to Disability Support Services (Montana State University - Billings)

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Release of Information to Disability Support Services (Montana State University - Billings)

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Release of Information to Disability Support Services
I hereby authorize __________________________________________________________ to:
Release to Disability Support Services at Montana State University Billings the information
specified below:
1. Diagnosis of individual’s condition.
2. Documentation of individual’s condition.
3. Recommendation for academic accommodations.
Name ________________________________________________________________________
(Last) (First) (Middle)
Email address _________________________________________________________________
Telephone (home) __________________________ (work/cell) ___________________________
Signature __________________________________________ Date ______________________
Return to Contact
MSU Billings tcarey@msubillings.edu
Disability Support Services greg.gerard@msubillings.edu
College of Education, Room 135 MSUB (406) 657-2283
1500 University Drive City College (406) 247-3029
Billings, MT 59101 Fax: (406) 657-1658
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Release of Information to Disability Support Services (Montana State University - Billings)

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Completed 24 August 2020

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