Fillable Authorization For Disclosure And Release Of Medical Information Form printable pdf download

University of Connecticut

Authorization for Disclosure and Release of Medical Information Form

Revised 10/13

As required by Connecticut law,

I, ____________________________________________ [employee's name] whose home

the Office of Diversity and Equity

address

__________________________________________________________________

may not use or disclose your

individually identifiable information

and whose date of birth is ______________________________________HEREBY AUTHORIZE

without your authorization.

_____________________________________________________________________________

Your completion of this form

[provider's name and contact information]

means that you are giving

to release medical information pertinent to the reasonable accommodation I requested to:

permission for the use(s) and

disclosure described below.

For Storrs and Regional Campuses:

Please review and complete this

Office of Diversity and Equity

form carefully. It may be invalid if

University of Connecticut

241 Glenbrook Road - Unit 4175

not fully completed.

Storrs, CT 06269-4175

Telephone - (860) 486-2943

Please forward this form, along

Facsimile - (860) 486-6771

with the Request for Reasonable

Accommodation Form to the Office

of Diversity and Equity upon

completion.

To any licensed physician, other licensed practitioner, hospital, clinic, or other medically

related facility, or United States Veteran Administration:

ODE USE ONLY

I authorize you to release to the Office of Diversity and Equity information to be used

solely for the purpose of evaluating my request for reasonable accommodation.

_______

Initial

This Authorization shall be valid for a period of 180 days after the date of mysignature or

earlier if revoked by me in writing to the Office of Diversity and Equity.

_______

Initial

Acknowledgement

I understand that the Office of Diversity and Equity may not use or disclose my medical

information except for the expressed purposes identified above, unless another authorization is

obtained from me or unless such use or disclosure is specifically required or permitted by law.

I understand that once this information is disclosed pursuant to this Authorization, it is no longer

protected by the Office of Diversity and Equity's privacy policies, and may possibly be re-

disclosed by the recipient.

I hereby acknowledge that I have been informed of my right to receive a copy of this authorization

request.

I acknowledge that I have the right to refuse to sign this Authorization.

I acknowledge that I may revoke this Authorization in writing at any time. I understand that if I

revoke this Authorization, the information described above may no longer be used or disclosed

for the purpose described in this written Authorization. To revoke this Authorization, please send

a written statement to:

For Storrs and regional campuses:

Office of Diversity and Equity

University of Connecticut

241 Glenbrook Road - Unit 4175

Storrs, CT 06269-4175

My signature below indicates that I have read and understand this Authorization and its terms.

___________________________________

__________________________________

Signature

Date

Authorization For Disclosure And Release Of Medical Information Form

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