Release of Information

Student Accessibility Services (SAS) maintains disability-related documentation for a limited time. Requests for documentation must be made as soon as possible.

By submitting this form, you authorize SAS to release your disability-related documentation to yourself or to a third party, including other institutions. This submission serves as your formal release of records and permission for SAS to share the specified documentation as indicated below.

Student Information

First Name

Preferred Name

Last Name

U#

SUNY Poly Email Address

Birthdate

What action should SAS take with your records?

I want SAS to send my records to me at my SUNY Poly email address

I want SAS to send records to my new school

I want SAS to request records from my medical provider, school district, or previous institution

I want SAS and another office/person on campus to share information about me for support purposes

SAS will send all disability documentation on file and an accommodation letter when available. If you prefer to only send specific documents or diagnoses, please choose "I want SAS to send my record to me at my SUNY Poly email address"

Name of the College/University receiving records

Name of office/department receiving the records (e.g., Disability Services, Accessibility Resources, etc)

Office or department email address or fax number (If using email, SAS will copy you in when records are sent)

Name of person or department you want SAS to communicate with

Name of the provider, school district, or college (Mohawk Valley Community College, Holland Patent School District, Utica Pediatrics, etc.)

Name of office/department (Student Accessibility Services, records department, Dr. Henderson, etc.)

Address of the provider, school district, or college

Phone number of the office/department, including area code

Authorization and Consent

By typing your name in the box below, you authorize Student Accessibility Services (SAS) to release, obtain, or share information or records as specified in this request. You understand that these records may include information related to your diagnosis and/or approved accommodations.

By typing your name, you confirm that you have read and understand this authorization and consent to SAS releasing, obtaining, or sharing your records or information as indicated in this form.

Typed name (serves as electronic signature):