Authorization For Release Of Protected Health Information Form
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1
2STATE OF DELAWARE
A
F
R
O
P
H
I
UTHORIZATION
OR
ELEASE
F
ROTECTED
EALTH
NFORMATION
This form is to be completed only when additional documentation is requested by the
employer. Circumstances include requests to provider for additional documentation
and/or requests to contact the provider for clarification on questions already completed on
ADA forms.
Part 1: Name of person whose health information will be disclosed:
Part 2: Person or Entity that has the health information to be released:
Health Care Provider: ____________________________________________________
(Print the name and address of the provider that has the record to be disclosed, e.g., Dr.
Jane Doe, ABC Laboratories, XYZ Hospital, etc. If you need to list more than one
health care provider, please provide an extra page with that information.)
Part 3: Description of the health information to be released:
My health information and medical records related to the request of reasonable
accommodation(s).
Other: ___________________________________________________________
(Describe health information that may be disclosed. Medical diagnosis is not requested.)
Part 4: Person or Entity that will receive the health information:
Statewide EEO Office, Statewide ADA Coordinator, State of Delaware,
(Confirm that title, department and state agency are correct, and fill in address
information.)
Part 5:
Description of the purpose for the release of the health information:
To support my request for: reasonable accommodation under ADA.
Part 6:
Duration of Authorization: This authorization will remain effective until the
earlier of (choose an expiration period):
Expiration period:
30 days
60 days
90 days
180 days
___days, or
Expiration event: The date the State of Delaware makes a final determination about my
request.
Part 7:
Certification and Acknowledgement: I certify that I am the person (or the
personal representative of the person) designated in Part 1. I agree that my individually
identifiable health information described in Part 3, and held by the person or entity listed
in Part 2, may be disclosed to the person or entity listed in Part 4 for the purpose(s)
designated in Part 5.
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