Occupational Medicine Exam Request Form And Authorization For Release Of Medical Information (Page 2 of 2) in pdf

Privacy Protection Policy

I hereby authorize the use and/or disclosure of my individually identifiable health information as described

below. I understand that the purpose of my visit is for the purpose of creating protected health information

for disclosure to my employer, North Carolina State University. Should I refuse to sign this authorization,

the examination requested will not be conducted, and certain tasks cannot be performed because they

require a medical examination. If this task is an essential job duty, lack of performance may result in

termination of my employment. I further understand that if the person(s) or organization authorized to

receive the information is not a health plan or health care provider, the released information could be re-

disclosed and would no longer be protected by federal privacy regulations.

1. Personal health information to be disclosed to other health providers: All medical information

obtained as a result of the examination identified above.

2. Health Providers (or class of persons) or organization authorized to provide the information:

Student Health Services, Duke Occupational Medicine, and ___________________ (write in name

of health care provider if not listed above or N/A for not applicable).

3. Purpose of the requested disclosure: Summarized information to be disclosed by the health

provider to those listed in item #4 below is to determine if the employee has a health condition

which may interfere with his/her job performance and to comply with OSHA regulations.

4. Person(s) or organization authorized to receive summarized information: My supervisor, Safety

Manager and the industrial hygiene section or Environmental Health and Safety occupational

medicine program will receive only summarized information as described in item 3 above.

5. I understand that I have a right to revoke this authorization at any time. My revocation must be in

writing in a letter provided to the Student Health Services. I am aware that my revocation is not

effective to the extent that the persons I have authorized to use and/or disclose my protected

health information have acted in reliance upon this authorization.

6. I understand that I will get a copy of this form after I sign it.

7. I have been provided with a copy of NC State University’s Notice of Privacy Practice prior to

signing this authorization. A copy of the Privacy Practice is located also on the EHSC’s Medical

Surveillance webpage at:

8. This authorization expires in one year.

____________________________________________

___________

Signature of Employee

Date

_____________________________________________

___________

Signature of Supervisor (required for exam request,

Date

NOT for release of medical information)

H/Forms/Medical Authorization, Rev. 7/04

Occupational Medicine Exam Request Form And Authorization For Release Of Medical Information Page 2