Form Appendix A Appendix A Sample Authorization Letter for the Release of Employee

OMB No. 1218-0065
Exp. Date xx/xx/2023

APPENDIX A TO §1910.1020—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

PAPERWORK REDUCTION ACT STATEMENT
Under the access to employee exposure and medical records standard, employers must, upon request, assure the
access of each designated representative to the employee medical records of any employee who has given the
designated representative specific written consent (29 CFR 1910. 1020(e)(2)(ii)(B)). Appendix A of the standard contains
a sample form which may be used to document written consent for access to employee medical records. According to
the Paperwork Reduction Act, an Agency may not conduct or sponsor, and no persons are required to respond to, a
collection of information unless such collection displays a valid OMB control number. Use of this sample form is entirely
optional. This sample form will assist employers to ensure compliant records access documentation. OSHA estimates
employer burden for the completion of this collection of information is 5 minutes (.08 hours) per request. These
estimates include the time for reviewing instructions, searching existing data sources, gathering and maintaining the
data needed, and, completing and reviewing the collection of information. Send comments regarding this burden
estimate or any other aspect of this collection of information, including suggestions for reducing this burden to
[email protected] or to OSHA's Directorate of Standards and Guidance, Department of Labor, Room N-3718, 200
Constitution Ave., NW, Washington, DC; 20210; Attn: Paperwork Reduction Act Comment. (This address is for
comments regarding this form only; DO NOT SEND ANY COMPLETED SAMPLE FORM TO THIS OFFICE.)
OMB Approval# 1218-0065; Expires: 00-00-0000