Sample Request For Medical Information Page 2

my ability to perform the functions of my position and any devices, equipment, or accommodations I

require to enable me to perform these functions.

I understand that I may revoke this authorization at any time by sending a written statement to

[employer name and address]. The statement must identify this authorization by referring to the date

it was signed (below). The statement must include the date on which this authorization is no longer in

force. I understand that if I revoke this authorization, my employer may still use and disclose

information for which an action has already been taken in reliance on this authorization.

______________________________

Printed Name

______________________________

Signature

______________________________

Date

[The original form must be signed and retained by the employer with a photocopy forwarded to the

physician.]

Revised 6/2013

0 votes

Parent category: Medical