I ________________________________, SS# _________________________, request all files related to my documented disability be released to Nicolette Campos. I understand the information requested is confidential in nature. This release is subject to revocation in writing at any time, but revocation can have no effect on disclosures previously made. This authorization expires without express revocation one year from the date, which appears below.
Signature of Client: _______________________________________
Nicolette Campos, MA
Director, Accessibility Resource Center
P.O. Box 1510
One University Drive
Pembroke, NC 28372
711 (NC Relay)