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"…of a different mind"

Email rogernmeyer@earthlink.net

Phone/FAX 503-666-2776

Cell:  503-358-6463

18162 E Burnside

Portland, OR  97233

 

AUTHORIZATION FOR DISABILITY

ADVOCACY

 

 

 

I, __________________________________________________, hereby authorize Roger N. Meyer, DBA "…of a different mind" to be my disability advocate with the agency or the professional listed below.

 

     Mr. Meyer is authorized to conduct conversations and official business relating to my disability with the person(s) and agency listed below.

 

     This authorization is effective as of the date of my signature, and can be revoked by me at any time.  If my case is transferred to another agent or professional within the agency, this agreement shall remain in force.  Absent my revocation, this authorization and release will remain in effect for ninety days following the closing of my case and/or file with the agency.

 

 

 

PERSON OR AGENCY___________________________________________________

 

Professional or agency address_____________________________________________

 

Purpose of consultation/contact_____________________________________________

 

________________________________________________________________________

 

 

 

X________________________________________       Date_______________________

                                                (SIGNATURE)

 

__________________________________________

ROGER N. MEYER

 

 

                         

Student and Adult Disability Advocacy               Professional In-Service Education                 Case Management

    Consultant on Non-Verbal Learning Disabilities, Asperger Syndrome and  High Functioning Autism

 

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