AUTHORIZATION FOR RELEASE OF INFORMATION
Name (please print) _________________________________________________________________________________
Student ID Number __________________________ DOB ______________________ Last 4 SSN ____________________
I, _________________________________ hereby request/authorize the release of confidential information
From:
_________________________________________________________________________________
_________________________________________________________________________________
_________________________________________________________________________________
To:
UH Hilo Disability Services
FAX: (808) 932-7768
I request that the following information be released: (Check all that apply)
□ IQ test results
□ Educational test results
□ Disability documentation
□ Diagnosis Statement
□ Treatment history
□ Medical test results
□ Mental health information
□ Substance abuse information
□ Other _______________________________________________________________________________________
The purpose of this disclosure is:
□ Coordination of Disability Services for existing client’s academic accommodations.
□ Determine new disability condition and accommodation
□ Update existing file
□ Other __________________________________________________________
I understand the purpose of this authorization for release of information requires that this information will be
considered as CONFIDENTIAL. I further realize the information will help my educational assessment plans and
coordination at UH Hilo. I understand that the information is to help UH Hilo make a decision when the information that
I have provided is not sufficient to understand the connection between the educational barriers, my disability, and the
request academic accommodations that I feel that I need. I have had an opportunity to ask questions and am satisfied
with the reason and purpose for which my permission is given.
I understand that I may revoke this release at any time; otherwise, this release will automatically expire one year from
today’s date, or the time that I am no longer enrolled at UH Hilo. No information released under the terms of this
authorization may be re-disclosed without the written permission of the student.
Please direct information released to, Director of Disability Services.
Student Signature ______________________________ Date ______________________
Parent/Guardian Signature _______________________ Date ______________________
DS Director ____________________________________ Date ______________________
UH Hilo Disability Services
cannot guarantee the
confidentiality of the
documents transferred by
fax. Please initial if you
want information to be
transmitted by fax.
Initials _______
Rev. July 2015