Authorization to Disclose

Form Approved

No. 0920-xxxx

Exp. Date xx/xx/20xx

Attachment F

AUTHORIZATION TO DISCLOSE HEALTH INFORMATION TO THE

NATIONAL INSTITUTE FOR OCCUPATIONAL SAFETY AND HEALTH

The National Institute for Occupational Safety and Health, (NIOSH), Centers for Disease

Control and Prevention, U.S. Department of Health and Human Services, is conducting a

research study of respiratory illness at the Umicore Thin Film Products plant in

Providence, Rhode Island. The purpose of this study is to determine if there is

respiratory illness related to exposures at this plant. As part of this study, NIOSH is

requesting permission to review the results of your medical tests that were conducted for

Umicore in the past and future tests to be conducted for Umicore during this study.

If you sign this document, you give permission to Corporate Care (Our Lady of Fatima Hospital) and future healthcare providers hired by Umicore to conduct medical testing to disclose your health information to NIOSH. NIOSH is a public health authority that is authorized by law to collect and receive such information for the purposes of preventing and controlling occupationally related disease, injury or disability and conducting public health surveillance, investigations or interventions.

When you sign this authorization, Corporate Care (Our Lady of Fatima Hospital) and future healthcare providers hired by Umicore may disclose to NIOSH a copy of your existing medical records and new medical records as they become available during this study.

Please note that you may revoke this Authorization at any time, except to the extent that NIOSH and Corporate Care (Our Lady of Fatima Hospital) and future healthcare providers hired by Umicore have already acted based on this Authorization. To revoke this authorization, you must write to Corporate Care (Our Lady of Fatima Hospital), 200 High Service Avenue, North Providence, RI 02904 and to future healthcare providers hired by Umicore and to Dr. Kristin Cummings, NIOSH, 1095 Willowdale Road, Morgantown, WV 26505.

Your providers are required by the Federal Privacy Rule under HIPAA to protect your health information. When they provide the information to NIOSH, it will not be protected by this same Federal Privacy Rule. However, NIOSH, as a federal agency, will continue to protect the confidentiality of your medical records to the extent it is permitted to do so under another Federal law, the Privacy Act. NIOSH will not disclose your identifiable health information that it receives under this Authorization without your written consent except where authorized to do so by law. NIOSH will present its findings from its investigation in a manner that does not identify you.

Name (print): _______________________________Date: ________________________

Signature: ________________________________Date of Birth: ___________________

Signature of NIOSH Representative: ______________________________________

AUTHORIZATION TO DISCLOSE HEALTH INFORMATION TO THE

NATIONAL INSTITUTE FOR OCCUPATIONAL SAFETY AND HEALTH

If you sign this document, you give permission to your health care providers listed below to disclose your health information to the National Institute for Occupational Safety and Health, (NIOSH), Centers for Disease Control and Prevention, U.S. Department of Health and Human Services, for its research study of respiratory illness at the Umicore Thin Film Products plant in Providence, Rhode Island. NIOSH is a public health authority that is authorized by law to collect and receive such information for the purposes of preventing and controlling occupationally related disease, injury or disability and conducting public health surveillance, investigations or interventions.

When you sign this authorization, your health care providers may disclose to NIOSH a copy of your medical record to include original chest x-rays, original CT scans and pathology slides and blocks.

Please note that you may revoke this Authorization at any time, except to the extent that NIOSH and the providers listed below have already acted based on this Authorization. To revoke this authorization, you must write to the providers listed below and Dr. Kristin Cummings, NIOSH, 1095 Willowdale Road, Morgantown, WV 26505.

Your providers are required by the Federal Privacy Rule under HIPAA to protect your health information. When they provide the information to NIOSH, it will not be protected by this same Federal Privacy Rule. However, NIOSH will continue to protect the confidentiality of your medical records to the extent it is permitted to do so under another Federal law, the Privacy Act. NIOSH will not disclose your identifiable health information that it receives under this Authorization without your written consent except where authorized to do so by law. NIOSH will present its findings from its investigation in a manner that does not identify you.

Doctor/Hospital Name Address Phone Number Fax Number

_______________________ _____________________________ __________________ _______________

_______________________ _____________________________ __________________ _______________

Doctor/Hospital Name Address Phone Number Fax Number

_______________________ _____________________________ __________________ _______________

_______________________ _____________________________ __________________ _______________

Doctor/Hospital Name Address Phone Number Fax Number

_______________________ _____________________________ __________________ _______________

_______________________ _____________________________ __________________ _______________

Employee Signature______________________ Date____________________ Date of Birth______________

Please Print Name ______________________ Phone Numbers_____________________________________

Umicore Thin Film Products

NIOSH Records Release Authorization: Corporate Care

Thank you for your participation in this survey of workers at Umicore Thin Film Products conducted by the National Institute for Occupational Safety and Health (NIOSH). Results from your medical tests will be sent to you at your home address.

Umicore requires that employees undergo periodic medical evaluation at Corporate Care (Our Lady of Fatima Hospital). If you want NIOSH to provide a copy of your test results from this survey to Corporate Care (Our Lady of Fatima Hospital), please complete this form. Once you sign this authorization, NIOSH will provide a copy of your test results to:

Corporate Care

Our Lady of Fatima Hospital

200 High Service Avenue
North Providence, RI 02904

Name (print): ___________________________________Date: __________________________

Signature: _____________________________________Date of Birth: ___________________

Signature of NIOSH Representative: ______________________________________

Public reporting burden of this collection of information is estimated to average 5 minutes per response, including the time for reviewing instructions, searching existing data sources, gathering and maintaining the data needed, and completing the collection of information. An agency may not conduct or sponsor, and a person is not required to respond to a collection of information unless it displays a currently valid OMB control number. Send comments regarding this burden estimate or any other aspect of this collection of information, including suggestions for reducing this burden to CDC/ATSDR Information Collection Review Office, 1600 Clifton Road NE, MS D-74, Atlanta, Georgia 30333; ATTN: PRA (0920-xxxx).