Authorization Form For Release Of Records printable pdf download

STATE OF ALASKA

DEPARTMENT OF COMMERCE AND ECONOMIC DEVELOPMENT

FOR OFFICE USE ONLY

DIVISION OF OCCUPATIONAL LICENSING

DATE

STATE MEDICAL BOARD

333 WILLOUGHBY AVENUE, NINTH FLOOR

P.O. BOX 110806, JUNEAU, ALASKA 99811-0806

(907) 465-2541

E-Mail: License@commerce.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, 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 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 as a mobile intensive care paramedic. 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

08-4004d (Rev. 12/97)

Authorization Form For Release Of Records