Employee Information: TO BE COMPLETED BY EMPLOYEE OR PATIENT
1. I1, (the patient or representative) hereby authorize and request the Health Care Provider noted below (and its agents) to release my protected health information (PHI) to : ABC Company for purposes of certifying my serious health condition under Federal and state FMLA and other leave laws
Health Care Provider: TO BE COMPLETE BY EMPLOYEE OR PATIENT
from (date) Date to (date) Date OR
all records relating to: Date from (date) Date - to(date) Date .
Certification and Acknowledgement: I certify that I am the person (or the personal representative of the person) designated in Part 1. I agree that my individually identifiable health information described in Parts 3 and 4, and held by the person or entity listed in Part 2, may be disclosed to the person or entity listed in Part 5 for the purpose(s) designated in Part 6. I understand that, if the information to be disclosed is needed by a health care plan in order to determine my eligibility for plan benefits; or is needed by ABC Company to consider me for medical, sick or other leave; or to consider my eligibility or claim for short- or long-term disability or life insurance coverage or benefits, workers’ compensation benefits, or similar fringe benefits; or to consider me for employment or continued employment, my failure to provide this Authorization may prevent me from receiving the benefit or leave, or preclude me from being considered for employment or continued employment. I understand that I have the right to revoke this Authorization, in writing, at any time, by sending the revocation to the person or entity who received the Authorization, and that the revocation will be effective except to the extent that the person or entity releasing the information has already taken action in reliance on my Authorization. I understand that, once disclosed, it is possible that the health information may be further disclosed by the recipient and no longer subject to protection under international, federal, state, or local privacy rules. I have received a copy of my signed Authorization.
Person to Release Information To
Attestation: I understand the nature of this authorization.
If this authorization is signed by a personal representative of the above-name patient, the personal representative must describe his or her authority to act:
* Witnesses only need if ABC Company requests witnesses as required by law