CONSENT TO RELEASE PERSONAL INFORMATION

CONSENT TO RELEASE PERSONAL INFORMATION

Michigan Department of Labor and Economic Opportunity Michigan Rehabilitation Services
I,*
Customer's Name
Birthday*

MonthDayYear
Date
(last 4 digits of Social Security Number)*
give my consent to Michigan Rehabilitation Services to release the following information or records, except where prohibited by law, for purposes directly connected to my vocational rehabilitation.*

Information about my disability, including if applicable, information regarding alcohol and drug abuse protected under 42 CFR, Part 2.Records regarding the diagnosis and treatment of HIV/AIDS or other communicable diseases defined by Public Act 174 of 1989.Medical RecordsResults of a work evaluation; results of a skill aptitude, or achievement tests; or reports regarding my performance in a training program.Accommodation prescriptions and recommendations.Case notes.Other (describe)
This information may be released to*

Any employers Michigan Rehabilitation Services may contact on my behalf.The following organization, individual, or specific employer:
"if selected" The following organization, individual, or specific employer:
The purpose of this release is for*

Conducting an assessment or evaluationPlanning AccommodationsAiding my participation in trainingProviding TreatmentHelping me develop or maintain a jobProviding EquipmentOther (describe)
This consent to release personal information is valid until the date....*

MonthDayYear
Date
or Event or Condition described below:
I may revoke this authorization in writing except to the extent that action has been taken in reliance on it. I also understand that I am not required to sign this release, but by doing so I can help myself get the services I need.
Customer Signature*

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Date*

MonthDayYear
Date
Parent or Guardian Signature (Where Required)

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Date

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Date
The Michigan Department of Labor and Economic Opportunity (LEO) does not discriminate agains t any individual or group because of race, religion, age, national origin, color, height, weight, marital status, genetic information, sex, sexual orientation, gender identity or expression, political beliefs or disability.
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