Accessibility Resource Center
Accessibility Resource Center
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Release of Information Form

To: ________________________________________

      ________________________________________

 

 

From: ______________________________________

           ______________________________________

 

 

RE:     ______________________________________

 

 

 

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: _______________________________________

 

Witness:           _______________________________________________

 

Date: __________________________________________________

 

Nicolette Campos, MA

Director, Accessibility Resource Center

P.O. Box 1510

One University Drive

Pembroke, NC 28372

Phone: 910.521.6695             

Fax: 910.521.6891

711 (NC Relay)

Email: nicolette.campos@uncp.edu

Website: www.uncp.edu/arc