RHRP-II Attachment 23 - RHRPII -6 Occ Health Form.pdf

RHRP-6, Rev. 9/11/98

RESERVE HEALTH READINESS PROGRAM

AUTHORIZATION FOR DISCLOSURE OF INFORMATION

(Pursuant To The Privacy Act of 1974, 5 U.S.C. 552a, 29 CFR 1910.1020, and 42 CFR Part 2)

(The release of information about a patient who is treated or referred for treatment for alcohol or drug abuse, or the medical results of such abuse, is governed by the Confidentiality of Alcohol and Drug Abuse Patient Record Regulations, 42 CFR Part 2).

TO:

Reserve Health Readiness Program Other

(name)

(address) (health center stamp)

You are hereby authorized to furnish information from the record of the individual named below which is in the record system of your facility, and release it to : (print or type - name, title and address)

1. Name of client or subject individual (print or type)

2. Agency

3. Purpose or need for the disclosure (please check)

COMPENSATION CLAIM(S)

OTHER HEALTH CARE PROVIDER

ATTORNEY

OTHER (Specify)

4. Specify extent and nature of information to be disclosed for each purpose or need indicated, and SPECIFY inclusive dates: from ___________ to_____________

This authorization is subject to revocation at any time except to the extent that DFOH or the other program specified which is to make the disclosure has already taken action in reliance on it. If this authorization has not been revoked otherwise, or has not expired in accordance with the terms of the duration statement provided above, it will expire upon the termination of the interagency agreement that authorized the services provided by Federal Occupational Health for the subject individual’s federal employer.

Any person who knowingly and willfully requests or obtains any record concerning an individual from a Federal agency under false pretenses shall be guilty of a misdemeanor and fined not more than $ 5,000 (5 U.S.C 552a(i)(3)); in the case of alcohol and drug abuse patient records, a falsified authorization for disclosure is prohibited under 42 CFR 2.31 and is punishable by a fine of not more than $500 for a first offense or a fine of not more than $5,000 for a subsequent offense, in accordance with 42 CFR 2.4.

5. Print Name of Client/Subject Individual: 6. If other than subject, indicate 7. Date of signature relationship or authority

8. Signature of Client/Subject Individual*: 9. Signature of Parent or Guardian, if minor*:

*A minor client/subject individual MUST sign if records to be released cover alcohol or substance abuse-related services.

X

MEDICAL MONITORING

Summary of the occupational health related finding from the base line or periodic general medical surveillance exam,including the resulting clearance,recommendations,and suggested follow-up.