Release and Receipt of Information Form

Faulkner University complies with all provisions of FERPA and HIPAA dealing with the release and/or receipt of medical and educational records within the Disability Services Office. No information concerning individuals receiving disability services, except as otherwise provided by law, will be released without the written consent of the student. It is the responsibility of the student to provide Disability Services with the necessary specific authorization and consent.

Please be advised that your disability record constitutes privileged information that is protected by the laws of the State of Alabama and may contain information protected under FERPA and HIPAA. Information shared with Professors consists of a list of required accommodations on a need to know basis. No disability specific information is shared by Disability Services, with Faulkner University faculty and / or staff. If not revoked earlier, this consent form expires upon graduation, or as specified below.

Student's name*

First Last

Student ID#*

Would you like to grant disabilities services permission to release your information to specified individuals?*

Yes
No

Signature*

I revoke my permission for Disability Services to release any information regarding my status.

I give my permission for Disability Services to release to or receive information regarding educational needs created by my disability to the individuals listed below:*

Name	Relationship to student	Receive information from (Y/N)	Release information to (Y/N)

Signature*

I have read, or have had read to me and fully understand the terms and conditions of this agreement and I agree that I am the person whose name appears on this form.

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Introduction

Release and Receipt of Information Form

Release and Receipt of information form