Request for Records/Release of Information form

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Office of Disability Resources D-101 Phone: 989-686-9794 Fax: 989-667-2202 E-mail: disabilityresources@delta.edu

Delta College Request for Records/Release of Information The purpose of this request for information is to determine my eligibility for reasonable and appropriate accommodations at Delta College. I, _______________________________________________

Birth date:____________________________

hereby authorize Delta College Disability Resources to _____ release / exchange information with: _____ request information from: Name / Agency ___________________________________________________________________________ Address: _________________________________ City: ________________ State: ________ Zip: _______ Phone #: _____________________________________ Fax #: _____________________________________ I understand that any copying/mailing costs associated with obtaining necessary third-party documentation are my responsibility, and will not be paid by Delta College or its representatives. Specific type of information requested:

All Information  Medication / Aids / Recommendations Accommodations Using / Requested  IEP and Psycho-Educational Evaluation including aptitude and achievement scores Diagnosis of Disability / Condition Functional Limitations Other:______________________________________________________________________________

The professional findings and proper documentation must, at the minimum, be provided on formal letterhead, in letter form, and signed by the professional, who is qualified to determine specific diagnosis. This document has been explained to me and I understand the contents. I understand that this consent may be revoked by me, in writing, at any time. It is valid only for the time reasonably necessary to accomplish its purpose. I further understand that all records, and subsequent communications, obtained by Delta College on my behalf, will be treated confidentially, and maintained separately from academic records. By signing this form I am agreeing to the information being released to Delta College for use in helping me plan my educational program, and secure appropriate resources and reasonable accommodations. Additionally I grant permission for communication between Evaluator and Delta College regarding information related to diagnostic assessments, evaluations, and for recommendations. Student’s Signature: _________________________________________________ Date: ________________ College Representative: ______________________________________________ Date: ________________