The University of the State of New York

THE STATE EDUCATION DEPARTMENT

Office of Adult Career and Continuing Education Services-Vocational Rehabilitation (ACCES-VR)

(Please read instructions on page two before completing this form

The Office of Adult Career and Continuing Education Services-Vocational Rehabilitation (ACCES-VR) has my permission to release or obtain information indicated in item #1 below. This information may include reports about my physical or mental condition, school records, facts necessary to determine my financial need, or other information that ACCES-VR needs to determine my eligibility and to provide vocational rehabilitation services. I understand that this information will be treated as confidential and privileged and will only be used for the purpose of obtaining services offered through ACCES-VR.

I understand that information disclosed according to this consent may be subject to re-disclosure and will no longer be subject to the HIPPA privacy requirements. I can change my mind about this release, by telling ACCES-VR in writing that I do not want any further information to be given out. This will not affect actions already taken with my permission.

My permission to release or obtain information expires on date from the date of signature, whichever is sooner.

3. Who is receiving this information? (Insert complete information about this person

I have read all of the information on this form. I understand and agree to what it says.

Consumer or Parent/Guardian Signature: Date:

This release meets all requirements of Title 45 section 164.508 of the Code of Federal Regulations, which implements HIPPA; Title 34 Part 99 of the Code of Federal Regulations, which implements the Family Education Rights and Privacy Act; and Title 42 Part 2 of the Code of Federal Regulations governing the confidentiality of alcohol and drug abuse records. Form VR-540, Prohibition on Redisclosure of Information Concerning Individuals with a Disability of Alcoholism or Substance Abuse, must be attached to this form when necessary.

The State Education Department does not discriminate on the basis of age, color, religion, creed, disability, marital status, veteran status, national origin, race, gender, genetic predisposition or carrier status, or sexual orientation in its educational programs, services and activities. Inquiries concerning this policy of nondiscrimination should be directed to the Department’s Office for Diversity, Ethics and Access, Room 530, Education Building, Albany, NY 12234

This Authorization to Release /Obtain Information form is to be used when information is to be released by or is to be requested by ACCES-VR. All such information will be treated as confidential and privileged and used only for the purposes of ACCES-VR services. Information ACCES-VR may have in the records, but obtained via a release from another provider, may be restricted from further dissemination.

If at any time the consumer wishes to terminate this release, he/she may do so by writing to ACCES-VR. Withdrawal of permission to release/obtain confidential information will not retroactively cover any information that has already been released or obtained.

• not leave any questions unanswered;

be as specific and precise as possible;

include a specific date on which the permission will end;

• include names of persons and titles or organization name receiving or

sending information; and mark the VR-22 as void if the consumer rescinds his/her permission in writing to release/obtain further information.

State the exact information that will be released/obtained (e.g., Medical Evaluation by Dr. Diaz dated 1/16/94; Educational Summary dated 10/5/95 from John Jay High School

State the name and title (if known) of the person releasing the information (e.g., Ms. Jean Jones, Vocational Rehabilitation Counselor; Dr. Browne, School Psychologist

Complete the name, title, and address of the person receiving the information. If an ACCES-VR counselor is sending the same document to several sources (e.g., a general medical report to a medical specialist and to an intake worker at a facility), multiple names, addresses, and titles can be filled in this box. It is not sufficient to indicate the report will be sent to a facility or program. A specific individual must be indicated, so that individual becomes responsible for the confidential information.

Provide a brief summary that indicates why the information is needed.

The consumer or parent/guardian must sign and date the form at the bottom. This date sets the timeframe for which information may be exchanged under this release form. If a different expiration date is to be established this must be indicated on the form.