Client Assistance Program
2401 NW 23rd, Ste 90,
Oklahoma City, OK 73107


RELEASE OF INFORMATION (Please print clearly)

NAME: _______________________	DOB: _________________	SS#: _____________

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:

1. 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;

2. Acknowledge that this authorization includes my confidential medical records;

3. Release any person, school, physician, hospital, or agency from any liability 
for furnishing information pursuant to this Release of Information; and

4. 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
Email: CAP@ohc.state.ok.us

Contact Data:
Are you a current Rehabilitation Services client? YES/NO

Name:						

Date/time of call:					

Mailing Address: 					

Phone: 						

Alt Phone:					

Fax:						

Email:						

The information listed below is required by Federal reporting requirements and 
will be included in the CAP annual report. Your personal information will not be 
a part of this report.
 
227 Reporting Data (required for annual report):

Age range: (16-21)  (22-40)  (41-64)  (65<)

Primary disabling condition of individual served: (Multiple responses are not 
permitted.)

1. Blindness (both eyes)

2. Other visual impairments

3. Deafness

4. Hard of hearing

5. Deaf-blind

6. Orthopedic impairments

7. Absence of extremities

8. Mental illness

9. Substance abuse (alcohol or drugs)

10. Mental retardation

11. Specific learning disabilities (SLD)

12. Neurological disorders

13. Respiratory disorders

14. Heart and other circulatory conditions

15. Digestive disorders

16. Genitourinary conditions

17. Speech impairments

18. AIDS/HIV positive

19. Traumatic brain injury (TBI)

20. All other disabilities

21. Disabilities not known


Ethnicity/Race: (Multiple responses are permitted.)

1. American Indian or Alaskan Native (List Tribe if known)

2. Asian

3. Native Hawaiian or Other Pacific Islander

4. Black or African American

5. Hispanic or Latino

6. White

7. Race/ethnicity unknown


Gender: 


Do you have a copy of your Individualized Plan of Employment (IPE or the PLAN)? YES / NO

Nature of Complaint:

ADA Title I				


Vocational Rehabilitation Issue (describe):	


Services delayed or denied?


Have you received a letter denying services or identifying a closure date?


Have you started an appeal of the denial?


Do you want CAP to represent you? YES/NO

?? Case information (after ROI received) ??

Counselor Name:					

Counselor phone:					

Counselor email					

Case number (or SSAN):				

Date of birth