Healthcare FMLA Document

AUTHORIZATION TO RELEASE PROTECTED HEALTH INFORMATION FOR FAMILY AND MEDICAL LEAVE ACT (FMLA) PURPOSES

Patient Name:   Date of Birth:   Employee ID (if applicable):

Employer / Requesting Party

Recipient / Healthcare Provider to Release Records

Authorization: Information to Be Disclosed

I authorize the above named healthcare provider to disclose the following protected health information to the Employer named above for the purpose of evaluating and administering Family and Medical Leave Act (FMLA) leave and related workplace accommodations. Select all categories to be released:

Diagnosis and relevant medical findings

Treatment plan, dates of visits, and anticipated course of care

Functional capacity, work restrictions, and limitations

Medication history and prescribing information

Laboratory, imaging, and test results related to the condition

Mental health records (excluding psychotherapy notes)

Psychotherapy notes (separate specific authorization required)   If checked, please initial to indicate specific consent:

Alcohol/substance use disorder treatment records (explicit authorization required)

From:   To:

Purpose of Disclosure

The information will be used for: Evaluation and support of FMLA leave Determination of workplace accommodations Other:

Method of Disclosure

Records may be disclosed via: Mail Fax Secure electronic transmission

Expiration and Revocation

This authorization will expire on:   or upon completion of the FMLA determination, whichever occurs first.

I understand that I may revoke this authorization at any time by sending a written notice to the healthcare provider listed above, except to the extent that action has already been taken in reliance on this authorization. Revocation does not affect disclosures already made in reliance on this authorization.

Redisclosure and Notices

I understand that once my protected health information is disclosed pursuant to this authorization, the information may be subject to redisclosure by the recipient and may no longer be protected by federal privacy regulations. I understand the Employer will use and maintain disclosed information in accordance with applicable privacy protections to the extent permitted by law.

I understand that refusal to sign this authorization will not affect my ability to obtain treatment from the provider, nor will it affect eligibility for benefits under FMLA; however, without my authorization my employer may be unable to process or grant FMLA leave based on medical information.

Acknowledgment and Patient Certification

By signing below, I certify that I am the patient named above or I am the patient's legally authorized representative. I authorize the release of the specified health information to the Employer for the purposes described. I acknowledge that I may receive a copy of this authorization upon request.

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