• Part Number:
    1910
  • Part Number Title:
    Occupational Safety and Health Standards
  • Subpart:
    1910 Subpart Z
  • Subpart Title:
    Toxic and Hazardous Substances
  • Standard Number:
  • Title:
    Sample authorization letter for the release of employee medical record information to a designated representative (Non-mandatory)
  • GPO Source:
I, _______, (full name of worker/patient) hereby authorize
__________ (individual or organization holding the medical records)
to release to _________ (individual or organization authorized to
receive the medical information), the following medical information
from my personal medical records:
___________________________________________________________________
___________________________________________________________________

(Describe generally the information desired to be released).

 I give my permission for this medical information to be used for
the following purpose:
___________________________________________________________________
___________________________________________________________________

but I do not give permission for any other use or re-disclosure of
this information.

 (Note: Several extra lines are provided below so that you can place
additional restrictions on this authorization letter if you want to.
You may, however, leave these lines blank. On the other hand, you may
want to (1) specify a particular expiration date for this letter (if
less than one year); (2) describe medical information to be created
in the future that you intend to be covered by this authorization
letter; or (3) describe portions of the medical information in your
records which you do not intend to be released as a result of this
letter.)
_____________________________________________________________________
_____________________________________________________________________
_____________________________________________________________________
_____________________________________________________________________

Full name of Employee or Legal Representative
_____________________________________________________________________

Signature of Employee or Legal Representative
_____________________________________________________________________

Date of Signature

 

[61 FR 31427, June 20, 1996]