Medical Information Release Form

MEDICAL INFORMATION RELEASE

FORM

I, ____________________________________________________________________ authorize

___________________________________________________________, to request and obtain

all records regarding any industrial accident / injury or occupational disease involving

myself and ____________________________________________________________________.

This is to include doctor’s reports, follow ups, nurse’s notes, and medical bills, test results, etc.

A facsimile or photo-static copy of this authorization shall be considered as effective and valid

as the original. The release shall remain in effect until specifically rescinded by me.

_____________________________________

_______________________________

Employee Signature

Date

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Parent category: Legal