Fill and Sign the Occupational Medicine Exam Request Form and Authorization

Basic form © James R. McDade (ver 05-24-06) 209-667-2300 AUTHORIZATION FOR DISCLOSURE OF MEDICAL INFORMATION Employers use this form when medical exams will occur. (Delete this note prior to use.)This authorization for disclosure of medical information is being given in compliance with the Confidentiality of Medical Information Act of 1981 (California Civil Code §56) and the federal HIPAA.I, _____________________________________, hereby authorize ____________________________________[name of employee or applicant] [name of physician, hospital, or testing center]to furnish to __________________________________________________ (hereinafter “Company”) [name of employer] the results and protected health information pertaining to the following marked tests and examinations: Alcohol Test Post-Offer, Pre-Employment Physical Examination Drug Test Doctor’s Assessment of Medical Ability to Perform JobOther (explain): ____________________________________________________ I authorize that the Company to ask questions about the above marked tests and examinations and to use my protected health information provided in response to this authorization to determine the following marked issues:Whether, as a job applicant, I can and am complying with the Company’s policy against using alcohol and illegal drugs (controlled substances) on the job. Whether, as an employee, I have violated Company policies regarding my having illegal drugs and alcohol in my system while on duty. Whether I am able to perform the essential functions of the job, with or without a reasonable accommodation. Whether I qualify (or continue to qualify) for a leave of absence or other employee benefit. Other (explain): __________________________________________________________I also authorize the Company to use my protected health information in defending against all claims arising out of any action that it may take in response to the results of the above-described test(s). Except as authorized above, the Company may not use or disclose my protected health information unless I provide another authorization, or unless such use or disclosure is specifically required or permitted by law.I understand that the Company will keep all protected health information confidential and in a file that is separate from my personnel file, with limited access to only those who need to know. Hence, I understand that re-disclosure of the protected health information by the Company to those who need to know is possible.This authorization shall become effective immediately and shall remain in effect for six (6) months from the date written below, after which time I must execute a new authorization before any medical information may be disclosed to or used by the Company. I understand that I may revoke this authorization at any time if I send a written notice revoking this authorization to the Company. However, this authorization cannot be revoked to the extent that the Company has taken action in reliance on the authorization prior to receiving the notice of revocation.I understand that treatment, payment, or enrollment in a health plan will not be affected if I refuse to sign this authorization. However, for an applicant seeking employment, failure to sign this authorization will result in the job offer being revoked. For a current employee being tested for illegal drug or alcohol use, failure to sign this authorization will result in the Company making a determination of whether a Company policy has been breached based on the information the Company has in the absence of a test result. For a current employee seeking a leave of absence or reasonable accommodation, failure to sign this authorization may result in the leave or accommodation being denied.I understand that I have the right to receive a copy of this authorization, at any time, upon my request.__________________________________ __________________________Employee / Applicant Signature Date