Authorization to release Information Live-in Aide Request

AUTHORIZATION TO RELEASE INFORMATION

REGARDING REQUIREMENT OF A LIVE-IN AIDE
RELEASE STATEMENT
I hereby authorize the above-named management agent to make inquiries regarding my need for a livein care attendant for the purpose of determining my eligibility for occupancy.
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THE FOLLOWING TO BE COMPLETED BY INFORMATION PROVIDER
Definition of Disabled
Under Federal law, an individual is disabled if he/she has a physical or mental impairment that substantially limits one or more major life activities; has a record of such impairment; or is regarded as having such impairment. The term physical or mental impairment includes, but is not limited to, such diseases and conditions as orthopedic, visual, speech, and hearing impairments, cerebral palsy, autism, epilepsy, muscular dystrophy, drug addiction, and alcoholism. This definition does not include any individual who is a drug addict and who is currently using illegal drugs or an alcoholic who poses a direct threat to property or safety because of alcohol use [24 CFR Part 8.3]

INFORMATION REQUESTED
Is the household member disabled as defined above?

YesNo
In your professional opinion, does the household member need the service of a live in aide in order to have the same opportunity that a non-disabled individual has to use to enjoy his/her residence?

YesNo
I ceritfy that the above information is true and correct to the best of my knowledge.
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AUTHORIZATION TO RELEASE INFORMATION