Privacy Issues in the Community College Workplace

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S AMPLE “C ONFIDENTIALITY IN M EDICAL I NFORMATION ” R ELEASE

AUTHORIZATION FOR RELEASE OF MEDICAL INFORMATION

I, __________________________, hereby authorize _______________________________ [employee name] [employer name]

to release the medical information described below to ________________________________. [name of recipient]

This authorization is limited to the following types of information: ______________________

____________________________________________________________________________ .

The recipient of this information may use it for the following purpose(s): _________________

____________________________________________________________________________ [e.g., to assess reasonable accommodations]

This authorization shall expire on _________________________________________________ [date]

I understand that I have the right to receive a copy of this authorization upon my request. By placing my initials in the margin to the right of this clause, I hereby acknowledge that a copy of this authorization has been received.

Signature: ___________________________ Dated: __________________________

NOTE: This authorization must be in a typeface no smaller than 14-point type, or it can be handwritten by the employee.

Privacy Issues in the Community College Workplace ©2019 (c) Liebert Cassidy Whitmore 208