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
to
disclose
to
the
Department
of
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