Outreach Services at Missouri School for the Blind
Release of Information Form

I understand that many agencies provide a variety of services and benefits. Each agency must have specific information in order to provide these services and benefits.
By signing this form, I am allowing the named agencies to exchange specific information to effectively provide or coordinate services and benefits. 

The parties agree that this agreement may be electronically signed. The parties agree that the electronic signatures appearing on this agreement are the same as handwritten signatures for the purposes of validity, enforceability, and admissibility. 
If you would prefer opt-out of signing this agreement electronically & prefer to sign an agreement manually, go to the MSB Outreach Website download the ROI form, and send it to mary.morrell@msb.dese.mo.gov

Question Title

* 1. Full name of the parent/guardian requesting an evaluation.

Question Title

* 2. Full name of the child for whom you are requesting an evaluation.

Question Title

* 3. Child's date of birth (MM/DD/YYYY)

Date

Question Title

* 4. Information of the medical provider/Ophthalmologist from whom we will request the eye report/medical history:

Question Title

* 5. Information of the school or early intervention program from whom we will request an IEP/IFSP/RED, etc:

The purpose of the exchanged/shared information is to:
  • Conduct Functional Vision and Learning Media Assessment (FVLMA)
  • Conduct Orientation and Mobility Assessment

This consent includes the following types of information:
  • Eye report/Ophthalmological report (Within the last 12 months.)
  • Hearing and audiological care (Within the last 12 months)
  • IFSP/IEP/504 Plan
  • ABC Checklist

Question Title

* 6. I understand:
  • The purposes of the exchanged information as described in the text above.
  • I have the right to inspect and receive a copy of the information to be shared. 
  • I am providing my consent voluntarily and I understand the information on this form. 
  • I have a right to revoke this release at any time. 
  • I understand that if I revoke this release, I must do so in writing and present my written revocation to Outreach Services, Missouri School for the Blind, 3815 Magnolia Ave, St. Louis, MO 63110.
  • I understand further that actions already taken based on this release, prior to revocation, will not be affected. 
  • The release of information will remain in effect for one year unless I specify an expiration date in the comments of this form. 
By clicking "I agree," you agree to the statements written above.

Question Title

* 7. Enter parent/guardian contact information.

Question Title

* 8. By typing my name below, I give my informed consent for information regarding the child whose name and date of birth are provided above to be mutually exchanged and shared between the provider who I named above and the Outreach Department at Missouri School for the Blind.

Question Title

* 9. Comments? (including expiration date of this Release of Information form if desired).

Outreach Services Contact Information:
Missouri School for the Blind
3815 Magnolia Avenue
St. Louis, MO 63110
FAX: 314-776-1875
For questions, call: 314-633-3930

T