Fillable CONSENT FOR RELEASE OF CONFIDENTIAL INFORMATION (Big Bend Community College)

Fill Online, Printable, Fillable, Blank CONSENT FOR RELEASE OF CONFIDENTIAL INFORMATION (Big Bend Community College) Form

Use Fill to complete blank online BIG BEND COMMUNITY COLLEGE pdf forms for free. Once completed you can sign your fillable form or send for signing. All forms are printable and downloadable.

CONSENT FOR RELEASE OF CONFIDENTIAL INFORMATION (Big Bend Community College)

On average this form takes 3 minutes to complete

The CONSENT FOR RELEASE OF CONFIDENTIAL INFORMATION (Big Bend Community College) form is 1 page long and contains:

  • 1 signature
  • 0 check-boxes
  • 9 other fields

Country of origin: US
File type: PDF

U.S.A. forms for Big Bend Community College

BROWSE BIG BEND COMMUNITY COLLEGE FORMS

Related forms
Fill has a huge library of thousands of forms all set up to be filled in easily and signed.
Fill in your chosen form
Sign the form using our drawing tool
Send to someone else to fill in and sign.
find another form
 
CONSENT FOR RELEASE OF CONFIDENTIAL INFORMATION
Disability Support Services (DSS)
TO:
Name of Agency/School
Address
City/State/Zip Code
FROM:
Student Name
Address
City/State/Zip Code
Date of Birth
You are hereby authorized to release pertinent medical, psychological, social or educational
information that the following agency and/or person may request about me. Send information
to:
Disability Support Services
Big Bend Community College
7662 Chanute Street NE.
Moses Lake, WA 98837
Phone: 509.793.2027
TDD: 509.793.2325
FAX: 509.762.3648
Information Requested:
This information will be used only as an aid in providing educational support services for which I
have applied.
The requesting agency/person has the responsibility of keeping this information confidential and
will not release this information to any other agency or person without my written consent.
Student Signature Date
Revised 6/4/18
click to sign
signature
click to edit
Download
Save PDF to desktop
Email
Email completed PDF
Send for Signing
Email for others to sign
Print
Print document
Choose a Field
Click on a field and
select the person that should complete it
Want to add a signature?
You can add a signature field
and assign it to someone else
to sign
Choose a Field
Click on a field and
select the person that should complete it

CONSENT FOR RELEASE OF CONFIDENTIAL INFORMATION (Big Bend Community College)

This document is locked as it has been sent for signing.

You have successfully completed this document.

Other parties need to complete fields in the document. You will recieve an email notification when the document has been completed by all parties.

This document has been signed by all parties.

Completed 8 October 2020

Message

View Audit Log
Print With Audit Log
Duplicate Document