Medical Information Release Form

MEDICAL INFORMATION RELEASE FORM

I, _____________________ authorize ERG Staffing Service to request and obtain all records

regarding any industrial accident / injury or occupational disease involving myself and ERG Staffing

Service. This is to include doctor's reports, follow - up reports, nurse's notes, medical

bills, test results, etc.

A facsimilie or photostatic copy of this authorization shall be considered as effective and

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 This release shall remain in effect until specifically rescinded by me.

Employee Signature

Date

0 votes

Parent category: Legal