2.02c Attachment 3, Authorization for Release of Medical Information.pdf

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Reasonable Accommodation Support Services
Solicitation number
N0018926QW008
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This document is an Authorization for Release of Medical Information form for the Department of the Navy. The form allows an individual to authorize their healthcare professional(s) to release medical information to Navy agency officials for the specific purpose of processing a reasonable accommodation request. The authorization enables Navy officials to confirm a medical condition as a disability under the Rehabilitation Act of 1973, understand functional limitations or work-related restrictions, receive clarification of previously submitted medical information, and obtain recommendations for potential accommodations that would enable the individual to perform essential job functions. The document emphasizes that the medical information will remain confidential and separate from official personnel records, with only relevant information shared with individuals directly involved in processing the accommodation request.

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Authorization for Release of Medical Information

AUTHORIZATION FOR RELEASE OF MEDICAL INFORMATION

By my signature on this document, I authorize ___________________________________ (name(s) of healthcare professional(s)) to release medical information to the following authorized contracted agency officials ____________________________solely to respond to my request for reasonable accommodation.

I understand that by providing permission to my healthcare professional(s) to release my medical information that pertains to my accommodation request, it will enable the Department of the Navy’s officials to:

• Confirm that my medical condition is a disability under the Rehabilitation Act of 1973, as amended;

• Understand the functional limitation(s) or work-related restrictions associated with my disability and why the requested accommodation is needed;

• Receive clarification of or a recent update regarding medical information previously submitted to the Department of the Navy, if applicable; or

• Obtain recommendations on any potential accommodation(s) that would enable me to perform the essential functions of my position.

The medical information collected will remain confidential and separate from my official personnel records, but I understand that relevant information may be shared with individuals directly involved in the processing of my reasonable accommodation request.

Signature Date

names of healthcare professionals to release medical information to the following:
Date:

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