Release of Information Medical Evaluation Results

Release of Information

Medical Evaluation Results

Candidate’s Name __________________________________________ Date ____/____/______

Printed (MM)/ (DD) (YYYY)

Address ___________________________________________________________ Unit #______________

City, State, Zip ___________________________________, __________________________, __________

Telephone _____-______-________ SSN XXX – XX -__________ Date of Birth ____/____/_______

(MM)/ (DD)/ (YYYY)

1. I hereby authorize the release of the following information to Comprehensive Health Services, Inc., TSA IHOPP Prime Contractor (Lockheed Martin), the Department of Homeland Security and the Transportation Security Administration:

Medical history, physical abilities test, medical exam, medical information or documents and all medical and drug test results.

2. I have the right to revoke this authorization within thirty (30) days by written notice to Comprehensive Health Services, Inc., TSA Program Manager for any disclosure already made in good faith, in reliance on this consent at the following address:

TSA Program Manager

c/o Comprehensive Health Services, Inc.

8810 Astronaut Blvd.

Cape Canaveral, FL 32920

3. I understand that this consent authorizes release to and between the above stated organizations.

4. All personal information collected by CHS is protected by the Privacy Act of 1974. Once medical information is disclosed to any of the above mentioned organizations, it is no longer protected by the health information privacy provisions of 45 CFR Parts 160 and 164 (mandated by the Health Insurance Portability and Accountability Act (HIPAA)) without limitation, the Federal Privacy Regulations, the Federal Security Regulations and the Federal Transaction Regulations. The information disclosed pursuant to this authorization may be subject to re-disclosure by the recipient and no longer protected under Federal Law.

5. The examining facility, clinic or physician, its employees, agents and officers and any attending medical personnel are released from legal responsibility or liability for the release of the above information to the extent indicated and authorized herein.

6. There is no expiration date for this release form.

______________________________________

Printed Name

Signed: ________________________________________ ______________________________

Candidate Date of Signature

PRIVACY ACT STATEMENT: AUTHORITY: 49 U.S.C. 44935 PRINCIPAL PURPOSE(S): This information will be used to determine your eligibility for employment as a Transportation Security Officer (TSO). ROUTINE USE(S): This information may be shared with contractors, grantees, or volunteers performing or working on a contract, service, grant, cooperative agreement, or job for the federal government, or for routine uses identified in the Office of Personnel Management’s system of records notice, OPM/GOVT-10 Employee Medical File System Records (if hired) or OPM/GOVT-5 Recruiting, Examining, and Placement Records (if not hired). DISCLOSURE: Voluntary; failure to furnish the requested information may result in an inability to consider your application for employment.

TSA Form 1130A-3, 12/09 [File: 1100.0.1]