Free Authorization Letter 32Free Authorization Letter 32
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Occupational Safety and Health Standards
Toxic and Hazardous Substances
1910.1020 App A
Sample authorization letter for the release of employee medical record
information to a designated representative (Non-mandatory)

I, _______, (full name of worker/patient) hereby authorize
__________ (individual or organization holding the medical
records)to release to _________ (individual or organization
authorized to receive the medical information), the following
medical information
from my personal medical records:

(Describe generally the information desired to be released).

I give my permission for this medical information to be used for
the following purpose:

but I do not give permission for any other use or re-disclosure of
this information.