Medical Clearance Form - Utah Attorney General printable pdf download

MEDICAL CLEARANCE FORM

Utah Code Ann. §17-22-8.1.

(A health care provider is authorized to disclose to a competent authority that a detainee is cleared for incarceration.)

NAME:

___________________________________

DOB: _________________

DATE:

_______________________

The above-named person IS

The above-named person IS NOT

MEDICALLY CLEARED for

incarceration

PROVIDER:

_____________________________________

____________________________________

Printed Name

Signature

MEDICAL FACILITY: _________________________________________________________

ADDRESS:

__________________________________________________________________

PHONE:

_________________________

IN CUSTODY OF:

__________________________________ ________________________

Name

Badge # / ID

Contact Information: ____________________________________________________________

Please note -- if the incarcerating institution needs more medical information about this

detainee, you may contact the facility AFTER THE DETAINEE HAS BEEN BOOKED if

the medical information is necessary for:

The provision of health care to this individual;

The health and safety of this individual or other inmates;

The health and safety of the officers, employees or others at the correctional institution;

The health and safety of this individual and officers or others responsible for transporting inmates;

Law enforcement on the premises of the correctional institution; and/or

The administration and maintenance of the safety, security and good order of the correctional institution.

(45 CFR A §164.512)

Substance abuse records are protected under federal law. If these records are requested, they can only be released by

(1) patient consent; (2) without patient consent only in a bona fide medical emergency; or (3) pursuant to a specific

type of court order. (42 USC §290dd-2)

Medical Clearance Form - Utah Attorney General