Attachment III Authorization for Medical Release.pdf
PDF 104 KB Posted
- Attached to
- Reasonable Accommodation Support Services
- Solicitation number
- N0018926QW012
About this file
This is an Authorization for Release of Medical Information form used by the Department of the Navy for reasonable accommodation requests.
The form authorizes named healthcare professional(s) to release medical information to authorized contracted agency officials solely for processing a reasonable accommodation request. The released medical information enables Department of the Navy officials to: confirm that the individual's medical condition qualifies as a disability under the Rehabilitation Act of 1973, as amended; understand functional limitations or work-related restrictions associated with the disability and the necessity of the requested accommodation; receive clarification or updates on previously submitted medical information; and obtain recommendations for potential accommodations that would enable the individual to perform essential job functions. The form specifies that collected medical information remains confidential and separate from official personnel records, though relevant information may be shared with individuals directly involved in processing the accommodation request. The form requires the individual's signature and date.
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Text version
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: |
File details come from the government source that posted it. Updated .