RELEASE OF CONFIDENTIAL INFORMATION AND RECORDS - Berrien RESA 2025

1. Click ‘Get Form’ to open it in the editor.
2. Begin by entering the Student Name and Date of Birth in the designated fields. This information is crucial for identifying the records requested.
3. Fill in the Date of Request for Information/Records and Age. Ensure accuracy as this will be used for processing your request.
4. Complete the District/School and PROVIDER sections with relevant details, including the name, address, city, state, telephone, fax, and zip code of the school or agency from which you are requesting information.
5. In the PURPOSE section, select one or more reasons for your request by checking the appropriate boxes. If necessary, specify any other purpose in the provided space.
6. Initial next to each type of Requested Information and Records you wish to obtain. This includes options like diagnoses and ongoing communication.
7. In the RECIPIENT section, provide your name and position along with Berrien RESA's contact details to ensure proper delivery of records.
8. Review the CONSENT section carefully. Sign and date where indicated to authorize the release of information. Make sure to check whether you authorize sharing or not.

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