Authorization Form For Release Of Records And Information Form printable pdf download

STATE OF MARYLAND – DRUG TESTING PROGRAM

Authorization Form for Release of Records and Information

A. Identification: This document authorizes the use and/or disclosure of confidential protected health information

about the following person:

Employee/Applicant Name: _______________________________ Social Security #: XXX-XX- ______________

Street Address: _____________________________ JobAps Easy ID# / SPS Employee ID#: ________________

City/State/Zip: _________________________________________

Date of Birth: ___________________________

Daytime Phone Number: (____) _________________

B. Directions for Release: I authorize the individual or company identified below in Section B.1b to release and/or

use protected health information identified in Section B.2 pertaining to the individual listed in Section A to the

individual or company identified in Section B.1a.

B.1a. I authorize the disclosure of information to:

State Personnel Services and State of Maryland Medical Review Officer

Appointing Authority (Identify) __________________________________________

For current State Employee, current Appointing Authority ______________________________________

B.1b.

I authorize the obtaining of information from:

Phamatech, Inc.

State of Maryland Medical Review Officer

B.2.

Information to be released: I authorize the disclosure and/or use of any information, including medical

information, laboratory results and medical opinions, relating to the specimen(s) collected from me on

(specify date of collection)__________________.

B.3.

Purpose: I authorize the disclosure and/or use for employment purposes.

B.4.

I am asking that you NOT provide any genetic information when responding to this request for medical

information. Genetic information, as defined by the Genetic Information Nondiscrimination Act of 2008,

includes an individual's family medical history, the results of an individual's or family member's genetic

tests, the fact that an individual or an individual's family member sought or received genetic services,

and genetic information of a fetus carried by an individual or an individual's family member or an

embryo lawfully held by an individual or family member receiving assistive reproductive services.

C. Right to Revoke: I understand that I may revoke this authorization at any time except to the extent that action

has already been taken in reliance upon it. This authorization will expire one year after the date it is signed. To

revoke the authorization, I must contact, in writing: Jennifer Hine, Director, Personnel Services, Department of

Budget and Management, 301 W. Preston Street, Room 705, Baltimore, MD 21201 or via Fax at 410-333-5440.

D. Authorization and Signature: I authorize the release of my confidential protected health information, as

described in my directions in Section B. I understand that this authorization is voluntary, the information to be

disclosed is protected by law, and the disclosure will conform with my directions. The information that is used

and/or disclosed pursuant to this authorization may be redisclosed by the recipient unless the recipient is

covered by Maryland law which prohibits redisclosure or other laws limiting the use and/or disclosure of my

confidential protected health information.

I have read the contents of this authorization and I confirm that the contents are consistent with my directions.

I understand that by signing this form, I am authorizing the use and/or disclosure of my confidential protected

health information.

_______________________________

_____________________________

______________________

Signature of Donor

Signature of Witness (ATR)

Date

●

Original - AGENCY ATR

Copy - EMPLOYEE

Copy - COLLECTION REPRESENTATIVE

HIPAA FORM FOR DRUG TESTING (Revised January 2016)

Authorization Form For Release Of Records And Information Form

Related Articles

Related forms

Related Categories