Application For A License To Practice Podiatric Medicine (Page 16 of 24) in pdf

ALASKA STATE MEDICAL BOARD

MED

Department of Commerce, Community, and Economic Development

For Office Use Only

Division of Corporations, Business, and Professional Licensing

(333 Willoughby Avenue – Ninth Floor)

Post Office Box 110806

Juneau AK 99811-0806

A – K: 907/465-2756

L – Z: 907/465-2541

E-Mail: medicalboard@alaska.gov

AUTHORIZATION FOR

RELEASE OF RECORDS

TO WHOM IT MAY CONCERN:

I, ________________________________________________________________________________________, residing at

(Please print full name)

___________________________________________________________________________, hereby authorize the Alaska

(Please print full address)

Division of Corporations, Business, and Professional 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 Corporations, Business, and Professional 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

08-4109a (Rev. 10/15/14)

Authorization for Release

Application For A License To Practice Podiatric Medicine Page 16

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