Form 08-4022 A - Authorization For Release Of Records
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1ALASKA STATE MEDICAL BOARD
MED
Department of Community and Economic Development
Division of Occupational Licensing
Office Use Only
(333 Willoughby Avenue - Ninth Floor)
Post Office Box 110806, Juneau Alaska 99811-0806
(907) 465-2541
E-Mail: license@dced.state.ak.us
AUTHORIZATION FOR
RELEASE OF RECORDS
TO WHOM IT MAY CONCERN:
I, ______________________________________________________________________________________, residing at
___________________________________________________________________________,
hereby
authorize
the
Alaska Division of Occupational Licensing and its investigators to examine my medical and dental records, employment
and education records including all training which pertains to my medical practice, and any records pertaining to litigation,
judgments, suits, and/or settlements, and any law enforcement records pertaining to me and discuss them with persons
having possession of them. I also expressly permit and authorize the release of any and all such records pertaining to me
to the Alaska Division of Occupational Licensing and its investigators. This release also applies to all records that pertain
to credentialing records at facilities at which I have applied for or held privileges to practice medicine.
I authorize the Division to discuss my records with persons or organizations that are considered appropriate by the
Division in connection with an official investigation, and to provide copies of my records to those persons or organizations
deemed appropriate by the Division.
This release also applies to any documents or records which contain information pertaining to psychiatric, psychological,
drug, or alcohol evaluation, counseling, diagnosis or treatment received by me and which were prepared or made in
conjunction with, or under the authority or guidance of any local, state, or federal law which relates to psychiatric, drug or
alcohol evaluation, diagnosis or treatment, including all information previously identified, collected, or stored under the
authority of any state or federal law, including 42 CFR Part 2.
I request that upon presentation of this release, or a Certified True Copy thereof, that you provide copies of those records
to the Division and/or its investigators, and/or representatives of the Office of the Attorney General of the State of Alaska.
This authorization expires one (1) year from the date of my signature below.
________________________________________________
___________________________________
Signature of Applicant
Date
________________________________________________
___________________________________
Home Phone Number
Work Phone Number
________________________________________________
___________________________________
Date of Birth
Social Security Number
08-4022 a (Rev 09/2000)
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