Authorization for Release of Health Information

I, ____________________________, hereby authorize the use or disclosure of my health information as described in this authorization.(1) Specific person/organization (or class of persons) authorized to provide the information:
(i.e. Insurance Company, Medical Personnel, Human Resources, etc.)

(2) Specific person/organization (or class of persons) authorized to receive and use the information: (i.e. Human Resources, Insurance Company, Medical Personnel, etc.)

(3) Specific description of the information: (For example, medical examination report and conclusions related to a fitness-to-work exam, results of drug testing for employment-related purposes).

(4) Right to revoke: I understand that I have the right to revoke this authorization at any time by notifying The Company in writing to Department, Employer’s name, Street address, City, Town, zip. I understand that the revocation is only effective after it is received and logged by The Company. I understand that any use or disclosure made prior to the revocation under this authorization will not be affected by a revocation.
(5) I understand that after this information is disclosed, federal law might not protect it and the recipient might redisclose it.
(6) I understand that I am entitled to receive a copy of this authorization.
(7) I understand that this authorization will expire when my employment terminates.

Signature of Requestor

__________________________ Date _____________