Medical Information Release Form

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MEDICAL INFORMATION RELEASE FORM
I, _____________________ authorize ERG Staffing Service to request and obtain all records
regarding any industrial accident / injury or occupational disease involving myself and ERG Staffing
Service. This is to include doctor's reports, follow - up reports, nurse's notes, medical
bills, test results, etc.
A facsimilie or photostatic copy of this authorization shall be considered as effective and
valid as the original. This release shall remain in effect until specifically rescinded by me.
Employee Signature
Date

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