UNC Electronic Letterhead

AUTHORIZATION FOR RELEASE OF INFORMATION

I authorize Accessibility Resources and Service at the University of North Carolina Chapel Hill to obtain and exchange information regarding my disability and/or medical condition(s) for the purpose of determining and managing services and accommodations in the post secondary education setting (as outlined by Section 504 of the Rehabilitation Act of 1973 and the Americans with Disabilities Act of 1990). I authorize that the information may be shared with appropriate personnel from Campus Health Services (CHS) and/or Counseling and Psychological Services (CAPS), at The University of North Carolina at Chapel Hill.

Student Name: PID: Phone: Address:

I authorize Accessibility Resources and Service to: (Check appropriate box) Documentation guidelines are available at http://accessibility.unc.edu

☐ Receive information from: Address:

Phone: Fax:

☐ Disclose information to (Person/Agency/Self) Address:

Phone: Fax:

Information to be released: (Check all that apply): ☐ Medical Records ☐ Academic information ☐ Psychological tests/reports ☐ Other (specify):

Form in which information should be released: (check the appropriate box) ☐ Verbal ☐ Written STUDENT’S SIGNATURE DATE

To the student: You may revoke this consent form at any time. Unless revoked earlier, this consent expires upon completion of your program at UNC Chapel Hill. A photocopy of this release shall be of the same force and effect as the original.