CONSENT TO RELEASE INFORMATION
CONSENT TO RELEASE INFORMATION I ________________________________________________, hereby authorize Department of Human Services, Division of Disabilities and Rehabilitation Services to obtain my medical records, summary or narrative of my protected health information relative to the Independent Living for Older Blind Program. ____________________________ _____________________________ Print Name Signature _____________________________ Date GOVERNMENT OF THE VIRGIN ISLANDS OF THE UNITED STATES Department of Human Services “Working Together to Make A Difference” DISABILITIES & REHABILITAION SERVICES 3011 Golden Rock • Christiansted, St. Croix, Virgin Islands 00820 • (340) 718-2980 ph. Knud Hansen Complex Bldg. A • 1303 Hospital Ground • St. Thomas, Virgin Islands 00802 • (340) 774-0930 ph.
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CONSENT TO RELEASE INFORMATION I ________________________________________________, hereby authorize Department of Human Services, Division of Disabilities and Rehabilitation Services to obtain my medical records, summary or narrative of my protected health information relative to the Independent Living for Older Blind Program. ____________________________ _____________________________ Print Name Signature _____________________________ Date GOVERNMENT OF THE VIRGIN ISLANDS OF THE UNITED STATES Department of Human Services “Working Together to Make A Difference” DISABILITIES & REHABILITAION SERVICES 3011 Golden Rock • Christiansted, St. Croix, Virgin Islands 00820 • (340) 718-2980 ph. Knud Hansen Complex Bldg. A • 1303 Hospital Ground • St. Thomas, Virgin Islands 00802 • (340) 774-0930 ph.