Office of Student Access & Accommodations: Release of Information Form

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MCPHS Office of Student Access & Accommodations: Release of Information Form

Monday through Friday 8:15am - 4:15pm Eastern

Fax: 617-608-5888

In order for the Office of Student Access & Accommodations to speak to or communicate with a party other than the student, the student must complete a Release of Information Form with OSAA. This is separate from any FERPA release forms or Release of Information Forms completed with other offices.

First Name

Last Name

Please use your MCPHS email

Release of Information Statement

I hereby authorize MCPHS Office of Student Access and Accommodations to release information for the purpose of:

Release Information To

I authorize MCPHS Office of Student Access and Accommodations to release information to (include name & relationship to student):

Understanding

I understand that this consent to disclose may be revoked by me at anytime by updating this form, or contacting OSAA in writing, except to the extent that action has already been taken.

Consent Expiration Date

This consent expires: