DELAWARE HEALTH AND SOCIAL SERVICES DIVISION FOR THE VISUALLY IMPAIRED AUTHORIZATION FOR THE RELEASE OF INFORMATION This authorization can be revoked in writing at any time, except to the extent that the information that has already been released in reliance on it before notice of the revocation is received. However, the Division for the Visually Impaired is not required to provide services to individuals who do not authorize access to information necessary for a determination and verification of their eligibility for services. Name: D.O.B.: SSN: I hereby authorize: To release to the Division for the Visually Impaired (DVI) my latest eye report or the specific information relating to my eye condition that is requested by DVI. The purpose of this request is to provide the necessary information to DVI so that a determination of my eligibility for their services can be made. This authorization expires on: MM/DD/YYYY Signature: _____________________________________ Date: _________________ Upon completion of this form, please return it to the Division for the Visually Impaired, Attention: DVI Intake 1901 N Dupont Hwy, Biggs Building New Castle, DE 19720 (302) 255-9800 Form DVI IU-01 Revised January 2004