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