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. 
 
 
 
 
 
 
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Print Name 
 
 
 
 
 
 
Signature 
 
 
 
 
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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.