Authorization for Release of Information
Client Assistance Program
1111 N Lee Ave
Oklahoma City, OK 73103
RELEASE OF INFORMATION (Please print clearly)
TO WHOM IT MAY CONCERN:
I have requested services from the State of Oklahoma Client Assistance Program
(CAP). In connection with such services I do hereby:
- Authorize and request any person, school, physician, clinic, hospital or
agency to furnish to CAP full and accurate social, education, psychiatric, and
medical documentation of any subject regarding myself and/or any other
information that might be helpful to CAP;
- Acknowledge that this authorization includes my confidential medical records;
- Release any person, school, physician, hospital, or agency from any liability
for furnishing information pursuant to this Release of Information; and
- Authorize appropriate U.S. Government officials to review the contents of my
CAP files including information released pursuant to this Release of
Information. Such review is to monitor CAP?s compliance with federal statutes.
Such officials may not disclose any personally identifiable information observed
in such review.
I understand that I am not required to use the Client Assistance Program to
dispute any actions affecting my rehabilitation program or appeal a decision of
the Department of Rehabilitation Services staff. My options also include
representing myself, asking a friend or family member to act as my
representative or hiring legal counsel at my own expense.
Copies of this form and signature are to be considered as valid as the original.
This release is valid for one (1) year from the date below and can be canceled
upon my written request to CAP at any time.
Signed:____________________________ Relationship: ________________________
Dated: ____________________________ Address: ________________________
Fax: (405) 522-6695
Voice: 800 522-8224