Below you will find a release of information as well as a list of service providers in Broward, Miami-Dade, and Monroe counties. The release will be important since some service providers may require a document from FIU-DRC acknowledging that you are working with our office, in addition to any forms they may need you to complete from their office. Please fill out this form in its entirety and feel free to ask you Access Consultant any questions you may have.
Support Service Evaluation has been recommended for the following student:
Name: _______________________________________________ Phone:__________________________________
Fax:_________________________________ Health Care Provider Contact:________________________________
I, _____________________________ ________hereby give the above mentioned health service provider and Florida International University’s Disability Resource Center permission to exchange information regarding my physical, mental, and/or emotional status. The purpose of this exchange is to benefit my educational pursuits and I may void this release at any time by written or verbal notice to either party mentioned above.