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.

Other (describe)
This information may be released to
"if selected" The following organization, individual, or specific employer:
The purpose of this release is for

Other (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
Date

MonthDayYear
Date
Parent or Guardian Signature (Where Required)
Date

MonthDayYear
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.
Should be Empty: