Attachment 24 Government Records.doc

AUTHORIZATION FOR RELEASE OF MEDICAL INFORMATION TO THE DSCC/OSU OCCUPATIONAL HEALTH PHYSICIAN

I, ____________________________ Date of Birth _____________________

Address: _____________________ SSN: ____________ (last 4 numbers only) _____________________ Home Phone: _____________________

Hereby authorize physicians and facilities to discuss, release, and furnish to the DSCC/OSU Occupational Health Physician medical information contained in the medical record regarding my medical case, evaluation, and/or treatment. This includes dates of treatment, condition, and diagnoses, testing results, procedures or surgeries.

I understand and acknowledge that this authorization extends to all or any part of the information designated above, and may include treatment for physical and metal illness, and /or alcohol/drug abuse, and/or AIDS (Acquired Immunodeficiency Syndrome), and/or may include the results of an HIV test or the fact that an HIV test was performed. I expressly consent to the release of the information designated above. This consent is valid for 60 days, unless revoked by my written notice, provided said notice is received prior to the release of the above-designated materials.

Signature of Patient Date

ATTACHMENT 24