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Consent to Release Information for Person with Disability (Form 1468/001)



Handle: Document-105
Owner: Laiche, Karen (User-23, klaich:DocuShare)DS
Friday, April 26, 2002 08:44:54 AM CDT
Thursday, February 24, 2005 11:52:06 AM CST
Modified By: Laiche, Karen (User-23, klaich:DocuShare)DS
Locked By:
  • PR-1468.1 December 17, 1996 CONSENT TO RELEASE INFORMATION Waiver of Confidentiality Form for Person with Disability All information that has been gathered on a person is personal and private, and you are not required to release this information.
  • PERSON WITH DISABILITY: Name: (1)_______________________________________________________ Date of Birth: ____/____/____ Address: (1)_______________________________________________________________________________ City:_____________________________________ State:____________________ Zip Code:______________ AUTHORIZED REPRESENTATIVE (If Applicable): Name: (2)________________________________________________________________________________ Address: ...
Allowed
Microsoft Office Word (.doc, .dot) - application/msword
1468-001.DOC
4
45056
No
Appears In: ALL FORMS - Alphabetically Listed by Form Title CLASSROOM/TEACHING FORMS DELGADO FORMS
Preferred Version: Consent to Release Information for Person with Disability (Form 1468/001)