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Subchapter 7. General Industry Safety Orders
Group 1. General Physical Conditions and Structures Orders
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§3204. Access to Employee Exposure and Medical Records - Appendix A

Appendix A

Sample Authorization Letter for the Release of Employee Medical Record Information to a Designated Representative

I, (full name of worker/patient) hereby authorize (individual or organization holding the medical records) to release to (individual or organization authorized to receive the medical information), the following medical information from my personal medical records:

(Describe generally the information desired to be released.)

I give my permission for this medical information to be used for the following purpose: , but I do not give permission for any other use or re-disclosure of this information.

(NOTE.--You may want to place additional restrictions on this authorization letter. For example, you may want to (1) specify a particular expiration date for this letter (if less than one year); (2) describe medical information to be created in the future that you intend to be covered by this authorization letter; or (3) describe portions of the medical information in your records which you do not intend to be released as a result of this letter.) [Your right of access to a specific written consent form submitted to your employer is provided by section 3204(e)(1)(D).]

Full name of Employee or Legal Representative

Signature of Employee or Legal Representative

Date of Signature

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