Authorization for Release of Information

HOUSING AND COMMUNITY DEVELOPMENT

AUTHORIZATION FOR RELEASE OF INFORMATION
RE: Household member with disability:

(Type Name of Household Member with Disability)Last Name
I herby authorize the release of information to Housing and Comunity Development (HCD) regarding the request for reasonable accomodation described on this form. This release shall constitute a limited authorization for the release of information, as described below.
I herby authorize Type Name of Health Care Provider/Documenting Authority) to consult with representatives of the Housing and Community Development (HCD), in writing, in person, or by telephone concerning the physical or mental impairment(s) that I assert to qualify as an individual with a disability for the sole purpose of this reasonable accommodation request.
For purposes of this Release, a "Qualified individual with a Disability" is defined as a person who has a pshyical or mental impairment that:

1. Substatially limits one or more major life activities

2. Has a record of such an impairment

3. Is regarded as having an imapriment

"A hysical or Mental Imapirment" is defined as:

1. Any psysiological disorder or condition cosmetic disfigurement, or anatomical loss affecting one or more of the body systems including, vut not limited to: neurological, musculoskeletal, special sense orgns, respiratory, and speech organs; or

2. Any mental of psycholoigcal disorder, such as mental retardation, organic brain syndrome, emotional or mental illness and specific learning disabilities.

The term "Physical or Mental Impairmen" includes, but is not limited to, such diseases and conditions as visual, speech and hearing impairments, epilepsy, multi sclerosis, cancer, etc.

"Major Life Activities" include functions such as caring for one's self, performing manual tasks, walking, seeing, hearing, speaking, breathing, leaning, and working.

"Has a Record of Such an Impairment (mental or physical)" means has a history of, or has been misclassified as having, a mental or physical impairment that substantially limits one or more major life activities.

"Is Regarded as Having Impairment" means:

1. Has a physical or mental impairment that does not substantially limit one or more major life activities, but is treated by a receipient as constitutiing such a limitation.

2. Has a physical or mental impairment that substantially limits one or more major life activities only has a result of the attitudes of others toward the impairment.

3. Has none of the impairments defined by Section 504's definiton of "physical or mental impairment", but is treated by a receipient as having such impairment.

In addition, I authorize Type Name of Health Care Provider/Documenting Authority) to provide only documentation that is necessary to verify that I meet the definition of a "Qualified Individual with a Disability", as defined above.
This Authorization solely authorizes the release of information necessary to verify the following:

1. Documentation necessary to verify that the person meets the definitions noted above;

2. A Description of the eeded accomodation; and,

3. A description of the identifiable relationship between my disability and the requested accomodations (s).

This Authorization for Release of Information should only seek information that is necessary to determine if the requested reasonable accomodation is needed because of a disability.

This Authorization does not authorize the HCD to examine my medical records, including diagnosis or test results(s); nor does this authorize the release of detiled information about the nature or severity of my disability.

The informaion/documentation released a result of this Authorization shall be kept confidential and not shared with anyone unless required to make or assess a decision to grant or deny a reasonable accomodation request.
Name of Household Member/Parent/Legal Guardian

First NameLast Name
Signature of Household Member/Parent/Legal Guardian

Clear
Date

MonthDayYear
Date
Relationship to Household Member/Resident
PLEASE PROVIDE THE FOLLOWING INFORMATION:
(1) Name of Health Care Provider/Documenting Authority:
(2) Address of Health Care Provider/Documenting Authority:

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
(3) Telephone Number of Health Care Provider/Documenting Authority:
Please enter a valid phone number.Format: (000) 000-0000.
(4) Facsimile Number of Health Care Provider/Documenting Authority:
Please enter a valid phone number.Format: (000) 000-0000.
This material is avilable in an accessible formation upon request. Please call the ADA Coordinator or Florida Relay Service TDD/TTY 800-955-8771 or email: ada.coordinator@miamidade.gov.
ASC/05/5110
Should be Empty:

HOUSING AND COMMUNITY DEVELOPMENT