Form 08-4020e - Authorization For Release Of Records printable pdf download

Form 08-4020e - Authorization For Release Of Records

NHA

Alaska Department of Community and Economic Development

Division of Occupational Licensing

Nursing Home Administrator Section

P.O. Box 110806, Juneau, Alaska 99811-0806

(907) 465-2695

E-mail: license@dced.state.ak.us

AUTHORIZATION FOR RELEASE OF RECORDS

To Whom It May Concern:

residing at

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

education records, and any records pertaining to litigation, suits, judgments 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.

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 to those persons or organizations considered 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 of guidance of

any local, state, or federal law which relates to psychiatric, drug or alcohol evaluation, diagnosis or treatment.

I request that upon presentation of this release, or a certified true copy of it, 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 is given expressly in connection with my application for initial issuance of a license as a nursing home administrator.

This authorization expires one year from the date of my signature below.

Signature:

Date:

Social Security Number:

Date of Birth:

Home Telephone:

Work Telephone:

08-4020e (Rev. 2/00)

(7)

Form 08-4020e - Authorization For Release Of Records