Authorization For Release Of Medical Information For Ada Purposes printable pdf download

Authorization For Release Of Medical Information For Ada Purposes

Authorization for

Release of Medical Information for ADA Purposes

TO: _________________________________________________________________________

Name of Medical Provider

_________________________________________________________________________

Address

_________________________________________________________________________

City State Zip Code

RE: _________________________________________________________________________

Name of Patient/ Birth date

_________________________________________________________________________

Address

_________________________________________________________________________

City State Zip Code

I hereby authorize __________________________________________________________________

Name of Medical Provider

disclose

the

Department

Health’s

agent/representative,

________________________________________________, or any other person, including the

Department’s legal counsel, who is authorized by my employer to handle medical information for ADA

purposes, any information concerning my physical or mental condition that is necessary to determine

whether I am a “Qualified Individual with a Disability” as defined by the ADA and to determine whether

reasonable accommodations can be made.

DOH/EO Medical Release Form for ADA Purposes-12/2013

Authorization For Release Of Medical Information For Ada Purposes