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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