Free Authorization Letter 32Free Authorization Letter 32
Download the document to the computer for easy use
There are more pages to preview,Read on

• Part Number:
• Part Title:
• Subpart:
• Subpart Title:
• Standard
Number:
• Title:
• GPO Source:

1910
Occupational Safety and Health Standards
Z
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)
e-CFR

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.
(No