Healthcare BLS Check Request

HEALTHCARE BLS CHECK REQUEST

Purpose: This form authorizes the release, verification, or retrieval of Basic Life Support (BLS) certification, course completion records, or skills check results for the named patient or registrant and requests issuance of any applicable administrative check or fee payment associated with processing. Completion of this form constitutes a limited authorization under applicable privacy laws permitting disclosure of the specified information to the designated recipient for the stated purpose.

Patient / Registrant Information

Date of birth:    Gender:

Primary phone:    Email:

Request Details

I request the following BLS-related records or actions (check all that apply):

BLS certification card/verification
Course completion certificate
Skills check documentation / checklist
Other (describe below)

Date range for records requested: From to

Recipient / Requestor (to receive records)

Recipient phone:    Recipient email:

Insurance Information (if applicable)

Policy number:    Group number:

Medical / Certification History

Authorization and Certifications

I hereby authorize the custodian of records to release, verify, or provide copies of the BLS certification, course completion, and skills check documentation described above to the named recipient for the stated purpose. This authorization includes disclosure of protected health information and training records necessary to confirm certification status and dates. I understand that the information released may include information related to emergency care, procedures performed during BLS training, and documentation of skills assessment.

I understand that I may revoke this authorization at any time by submitting a written notice to the records custodian, except to the extent that action has already been taken in reliance on this authorization. This authorization will expire on: unless an earlier date is specified here:

I understand that information disclosed pursuant to this authorization may be subject to re-disclosure by the recipient and may no longer be protected by privacy laws. The facility and its employees are released from liability for disclosures made in accordance with this authorization.

Fees and Check Request (if payment required)

Some requests may incur reproduction, administrative, or courier fees. I request issuance of an administrative check (if applicable) to the payee identified below to cover such fees or to reimburse training/course fees.

I authorize billing or deduction of applicable administrative fees to be paid from the listed insurance or by the payee indicated. I agree to pay applicable fees.

Attestation

By signing below I certify that the information provided on this form is true and correct to the best of my knowledge. I understand that knowingly providing false information may subject me to legal liabilities. I authorize the use of the information provided for processing this request and for verifying eligibility or certification status as required.

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