Department of Human Services/ Disabilities & Vocational Rehabilitation Services
Department of Human Services/ Disabilities & Vocational Rehabilitation Services Authorization to Release Information I, hereby authorize the release / request of the following information for the purposes of provision of vocational rehabilitation services. Staff Person requesting information: Name Address Title Telephone/ Fax Specific Nature of Information to be released I requested & purpose: Agency Staff releasing / receiving information: Name Address Title Telephone / Fax I recognize that I may revoke authorization upon written notice (except to the extent that material has already been obtained or released based on the authorization) and that such authorization shall automatically expire one year from the date I signed this form unless otherwise indicated below. Expiration date I certify that I have read the statement above and that I agree to its content Participant Signature Legal Guardian (if applicable) Date Date DRS-VR 11-2014 Authorization to Release Information
Download the original document · Plain text (TXT) · Browse the archive · How this archive works
Original source: https://dhs.vi.gov/wp-content/uploads/2023/03/VocRehab_Authorization-Consent-for-release-form.pdf
SHA-256 ed157c23a3b82b2df6c1aec91d2df6ef7b3223c270d44ddf84f7a3218a358af0
Re-using this document
territorial public record
Our description, tagging, arrangement, extracted text and machine transcripts are released under CC0 1.0. We assert nothing about the document itself.
Archive identifier LF-ed157c23a3b8
Document text
Department of Human Services/ Disabilities & Vocational Rehabilitation Services Authorization to Release Information I, hereby authorize the release / request of the following information for the purposes of provision of vocational rehabilitation services. Staff Person requesting information: Name Address Title Telephone/ Fax Specific Nature of Information to be released I requested & purpose: Agency Staff releasing / receiving information: Name Address Title Telephone / Fax I recognize that I may revoke authorization upon written notice (except to the extent that material has already been obtained or released based on the authorization) and that such authorization shall automatically expire one year from the date I signed this form unless otherwise indicated below. Expiration date I certify that I have read the statement above and that I agree to its content Participant Signature Legal Guardian (if applicable) Date Date DRS-VR 11-2014 Authorization to Release Information