1910.1020 Appendix A

Regulations (Standards - 29 CFR)

Sample authorization letter for the release of employee medical
record information to a designated representative (Nonmandatory) - 1910.1020 App A
Regulations (Standards - 29 CFR) - Table of Contents

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Part Number:
Part Title:
Subpart:
Subpart Title:
Standard Number:
Title:

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)

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.
(Note: Several extra lines are provided below so that you can place
additional restrictions on this authorization letter if you want to.
You may, however, leave these lines blank. On the other hand, you may
want to (1) specify a particular expiration date for this letter (if
less than one year); (2) describe medical information to be created
in the future that you intend to be covered by this authorization
letter; or (3) describe portions of the medical information in your
records which you do not intend to be released as a result of this
letter.)
_____________________________________________________________________
_____________________________________________________________________
_____________________________________________________________________
_____________________________________________________________________
Full name of Employee or Legal Representative
_____________________________________________________________________
Signature of Employee or Legal Representative
_____________________________________________________________________

Date of Signature

[61 FR 31427, June 20, 1996]