Download AUTHORIZATION TO RELEASE INFORMATION TEXAS A&M UNIVERSITY – COMMERCE

AUTHORIZATION TO RELEASE INFORMATION
TEXAS A&M UNIVERSITY – COMMERCE
Student Disability Resources and Services
Information is requested on:
Send Information to:
Student Name:______________________________
Rebecca Tuerk
Date of Birth:_______________________________ Student Disability Resources & Services
Campus ID #:_______________________________
P.O. Box 3011
Physician Phone/Fax # to contact:_______________
Commerce, TX 75429-3011
Phone (903) 886-5835 Fax (903) 468-8148
To Whom It May Concern:_________________________________________________
(name of organization or individual physician)
I have requested services from the Office of Student Disability Resources & Services (SDRS) at Texas
A&M University-Commerce. In connection with such services I do hereby:
1. Authorize and request any person, school, physician, clinic, hospital or agency to furnish SDRS
full and accurate social, education, psychiatric, and medical documentation of any subject
regarding myself and/or any other information that might be helpful to SDRS;
2. Acknowledge that this authorization includes my confidential medical records;
3. Release any person, school, physician, hospital, or agency from any liability for furnishing
information pursuant to this Release of Information.
Please fax the following information:
_____ Psychological Information
_____ Alcohol and Drug Treatment
_____ Medical Treatment
_____ School Records
_____ Other __________________________________
Dates of treatment or attendance requested: ____________________________________
This authorization will be in force while I am a student at Texas A&M University – Commerce unless
revoked by my written notice. Copies of this form and signature are to be considered as valid as the
original.
__________________________ _____________ ______________________ ____________
Student Signature
Date
Parent Signature
Date
(if appropriate)
The purpose of this requested information is for use in the administration of the student’s ACADEMIC
program. The confidentiality of this information will be protected under one or more of the following
federal and state laws and implementing regulations:
1.
2.
3.
4.
5.
Section 111.057, Human Resources Code, V.T.C.A.
Rehabilitation Act of 1973, as amended
Drug and Alcohol Abuse Acts, as amended (P.L. 93-282)
Social Security Act, as amended
Privacy Act of 1974
Student Disability Resources & Services
Representative
Date