Permission to Release Information
Please release medical information regarding my disability to Montana State
University-Billings. Reports need to be on letterhead and signed by a licensed or
otherwise properly credentialed professional. Medical reports should include the
following:
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A diagnostic statement identifying the disability
A description of the current functional limitations
A description of the expected progression or stability of the disability
A description of current and past accommodations, services and/or
medications
Recommendations for accommodations, adaptive devices, assistive
services, compensatory strategies, and/or collateral support services
Send information to: Montana State University Billings
1500 University Drive
Billings, MT 59101
(406) 657-2283
(406) 545-2518 VP
(406) 657-1658 Fax
tcarey@msubillings.edu
www.msubillings.edu/dss
City College
3803 Central Avenue
Billings, MT 59102
(406) 247-3029
(406) 545-1026 VP
jack.underwood1@msubillings.edu
Name
Date
Witness
Date