Authorization For Release Of Medical Information For Ada Purposes (Page 2 of 2) in pdf

Authorization For Release Of Medical Information For Ada Purposes Page 2

I also authorize ________________________________________________, or any other person who is

authorized by my employer to handle medical information for ADA purposes, to speak to my treating

physician or health care provider directly in regards to any questions he/she may have with respect to

my condition that relates to the performance of the essential functions of my job and any

accommodations that may be necessary.

I understand that the requested data is for the above-mentioned purposes, and that I may refuse to

provide the requested medical information. However, I understand that if I refuse to provide the

information, my employer may be unable to provide reasonable accommodations.

This authorization is valid for ninety (90) days from the date indicated below or upon receipt of my

signed written notice to withdraw my consent. A photocopy or facsimile is as valid as the original.

________________________________________________________________________

Signature of Patient/Employee Date

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

Authorization For Release Of Medical Information For Ada Purposes Page 2