INFORMATION REQUEST AUTHORIZATION TO RELEASE PERSONAL INFORMATION

INFORMATION REQUEST AUTHORIZATION TO RELEASE PERSONAL INFORMATION

Michigan Department of Labor and Economic Opportunity Michigan Rehabilitation Services
***FOR OFFICE USE ONLY***
Counselor Name
I,*
Customer Name
Birthday*

MonthDayYear
Date
Last 4 of Social Security Number*
NOTICE: The Administrative Simplification provisions in Subtitle F of Title II under the Health Insurance Portability and Accountability Act of 1996 (HIPAA) and in 45 CFR Parts 160 and 162 – do not apply to State Vocational Rehabilitation Agencies.
Specific type(s) of information to be disclosed:*

Medical and psychological records for physical and/or mental illnessDischarge SummaryMedicationsAssessmentHistory and PhysicalDiagnosisTreatment Plan RecordAlcohol and drug abuse treatment information protected under the regulations in Title 42 of Federal Regulations Part IIAcademic, Vocational, and/or Special Education informationInformation about Human Immunodeficiency Virus (HIV), Acquired Immune Deficiency Syndrome (AIDS), or other communicable and severe communicable diseases as defined by Public Act 174 of 1989.Other (specify)
The purpose(s) and need for such disclosure

Establish eligibility for vocational rehabilitation services.Determine need for and/or type of treatment or accommodation as needed by the customer.Develop and carry out vocational rehabilitation planning.Other (specify)
- I understand that, in order to accomplish the above need for disclosure, it may be necessary for Michigan Rehabilitation Services (MRS) to share my records with others. I grant MRS permission to do so except for records that can only be legally released if I sign a separate written consent. I understand this permission to release information includes any follow-up written or verbal exchange needed to carry out the purpose of the disclosure with the above referenced hospital, clinic, agency, school or individual.
- I understand that, under federal law, I can have access to information in my case file (34 CFR 361.38), except:
  - a. If the file contains medical, psychological, or other information that may be harmful to me, it may only be released to an appropriately identified third party.
  - b. If the file contains personal information obtained from another source, it may only be released under the conditions established by the source that has provided the information to MRS.
- I understand that, under the Rehabilitation Act, personal information obtained from another source may only be re- released under the conditions established by the source that has provided the information to MRS.
- I understand that I can refuse to give permission for MRS to obtain information about me from other sources. However, I also understand that if my refusal results in MRS being unable to determine my eligibility or my refusal unreasonably interferes with my vocational program, my case may be delayed or closed.
- I understand that I may revoke the consent provided in this form at any time, by providing MRS with a signed and dated written notice. My consent shall remain valid for so long as I am an active customer of MRS unless otherwise specified below. If this box is initialed, my consent expires upon the following:
Initials*

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Date*

MonthDayYear
Date
Or Event
Customer's Signature*

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Date*

MonthDayYear
Date
Parent’s or Legal Guardian’s Signature, if applicable

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Relationship
Date

MonthDayYear
Date
Mailing Instructions: Print copy of signed release for customer file, mail original to hospital, clinic, agency, school or individual.

The Michigan Department of Labor and Economic Opportunity (LEO) does not discriminate against 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. MRS-24 (Rev. 10-15)
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