Authorization To Obtain And Release Records And Information printable pdf download

Los Angeles County Employees Retirement Association

300 N. Lake Ave., Pasadena, CA 91101

PO Box 7060, Pasadena, CA 91109-7060

626/564-6132 • 800/786-6464

AUTHORIZATION TO OBTAIN AND RELEASE

RECORDS AND INFORMATION

I, ____________________________________________, hereby authorize the Los Angeles

County Employees Retirement Association (LACERA) to procure and have in its possession any

and all medical and psychological information from the following locations:

_________________________________________________________________________________

I understand this includes, but is not limited to, hospital and other records; test results including

x-rays, HIV test(s), and lab reports; medical and psychological records, notes, and reports; and

records and/or results from any providers of services. This also includes any and all records

pertaining to alcohol and/or substance abuse treatment.

I hereby authorize LACERA to procure any and all information, including sealed and unsealed

documents in the personnel file, payroll and other records, reports, and/or items concerning my

employment.

I hereby authorize LACERA to procure police and/or other reports concerning any incident in which

I have been involved.

I acknowledge a photocopy of this document shall be as valid as the original.

I understand I may receive a copy of this Authorization at any time.

7. I understand I may revoke this Authorization by filing a written revocation with LACERA’s Disability

Retirement Services. I understand by revoking this Authorization, my Disability Application will be

subject to rejection.

I understand information provided to LACERA may be subject to redisclosure and LACERA cannot

guarantee its protection.

I understand LACERA is materially relying on the information provided pursuant to this

Authorization.

NOTE: This Authorization is valid for three (3) years.

Signature: _________________________________________ Date: __________________________

Social Security No.: ______________________________ Employee No.: _____________________

Kaiser Medical Record No. (if applicable): _______________________________________________

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Authorization To Obtain And Release Records And Information