Release of Information to Health Care Provider

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Release of Information to Health Care Provider
I give my permission to a representative of the Office of Disability Services (ODS) to discuss my
disability with my health care provider (your provider may require you to sign a release as well).
Name of Health Care provider: ______________________________
Phone Number of provider:
(_______)______________________
Fax Number of provider:
(_______)______________________
Address of provider:
____________________________
____________________________
____________________________
I understand that I may revoke this consent at any time upon written request.
_________________________________________________________________________
Student Signature / Date
_________________________________________________________________________
Printed Name / MUID
_________________________________________________________________________
Office of Disability Services Representative / Date
Office of Disability Services Marquette University P.O. Box 1881 Milwaukee, WI 53201
Phone: 414-288-1645 Fax: 414-288-5799
ODS 07/2013
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