Authorization Form For Release Of Records printable pdf download

DPM

STATE OF ALASKA

FOR OFFICE USE ONLY

DEPARTMENT OF COMMUNITY AND ECONOMIC DEVELOPMENT

DIVISION OF OCCUPATIONAL LICENSING

STATE MEDICAL BOARD

P.O. 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:

, residing at

, hereby

authorize the Alaska Division of Occupational Licensing and its investigators to examine my medical and dental records,

employment and educational records, and any records pertaining to litigation, judgements, 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 podiatry.

I authorize the Division to discuss my records with persons or organizations which are considered appropriate by the

Division in connection with an official investigation, and to provide copies of my records of those persons or organizations

deemed appropriate by the Division.

This release also applies to any documents or records which contain information pertaining to psychiatric, drug or alcohol

evaluation, 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, 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 is given expressly in connection with my application for initial issuance or renewal or reactivation for

Alaska license to practice medicine, podiatry, a locum tenens, or resident permit to practice medicine, or a physician

assistant license, or mobile intensive care paramedic license. This authorization expires one year from the date of my

signature.

Signature of Applicant

Date

Home Telephone Number

Work Telephone Number

Date of Birth

Social Security Number

08-4109a (Rev. 10/99)

Authorization Form For Release Of Records