Authorization to Release Medical Information
(Thank you to the City of St. Paul, MN for providing the basis for this form.)
Health Care Provider:
The Genetic Information Nondiscrimination Act of 2008 (GINA) prohibits employers and other
entities covered by GINA Title II from requesting or requiring genetic information of an
individual or family member of the individual, except as specifically allowed by this law. To
comply with this law, we are asking that you not provide any genetic information when
responding to this request for medical information. “Genetic information” as defined by GINA,
includes an individual’s family medical history, the results of an individual’s or family member’s
genetic tests, the fact that an individual or an individual’s family member sought or received
genetic services, and genetic information of a fetus carried by an individual or an individual’s
family member or an embryo lawfully held by an individual or family member receiving
assistive reproductive services. (29 C.F.R. 1635.8(b)(1)(i)(B))
Effective as of ____________, 20___
Employee Name (please print) _____________________________________________________
Phone #_____________________________
Birthdate: ____________________
Address ________________________________________________________________
City ___________________________________ State___________ Zip___________
I hereby authorize the use or disclosure of my individually identifiable health information as
described below.
1. Any information concerning a physical or mental condition that may place work
limitations for me to perform my job functions. This authorization specifically includes
records prepared prior to the date of this authorization and records prepared after the date
of this authorization.
2. The purpose of this disclosure is for my employer to evaluate an accommodation request
and determine whether any other accommodations can be made.
3. Health care provider authorized to use or disclose the information:
_____________________________________________________________________________
Name of Health Care Provider
______________________________________________________________________________
Address
______________________________________________________________________________
City
State
Zip
4. ______________________________________, or any other person, including the City
of ________________ legal counsel, who is authorized by my employer to handle
medical information for Americans with Disabilities Act (ADA)/and Minnesota Human
Rights Act (MHRA) is authorized to receive the information.
5. My refusal to sign will not affect my eligibility for benefits or enrollment under the group
health plan sponsored by my employer, payment for or coverage of services under the
group health plan sponsored by my employer, or ability to obtain treatment under the
group health plan sponsored by my employer.
6. I understand that I may inspect or copy the information used or disclosed.
7. I understand that the requested data is for the above-mentioned purposes, and that I may
refuse to provide the requested medical information. However, I understand that if I
refuse to provide the information, my employer may refuse to provide an
accommodation.
8. This authorization is to be considered a complete and unconditional release of all records
of information as may be requested. A photocopy of this authorization shall be
considered as effective and valid as the original.
9. I understand that I may revoke this authorization at any time by notifying (city’s HR
Dept. or other accommodation coordinator), in writing except to the extent that:
a.
Action has already been taken in reliance on this authorization, or
b.
If this authorization is obtained as a condition of obtaining insurance coverage,
other law provides the insurer with the right to contest a claim under the policy or the
policy itself.
A revocation of this authorization must be dated and signed by me, specifically stating
that I am revoking this authorization. I may revoke this authorization by delivering or
mailing a written statement to the health care entity identified above, dated and signed by
me, stating that I am revoking this authorization (unless another method of revocation is
identified in the Privacy Notice of the health care entity identified above). If not
previously revoked, this authorization will expire one (1) year after the date I or my
authorized representative signs it, or earlier if so required by applicable law.
10. I understand that I have a right to request and receive a Notice of Privacy Practices from
my health care providers.
11. I understand that my health information is protected by federal regulations, specifically
including HIPAA, 45 CFR Parts 160 and 164. I also understand that certain drug and
alcohol abuse records, if any, may also be protected under 42 CFR Part 2.
I understand that, except as provided below, information to be disclosed may be subject
to re-disclosure by those receiving it and may no longer be protected by the federal
HIPAA regulations cited above. Drug and alcohol abuse records which are protected
under 42 CFR Part 2, however, are generally not subject to re-disclosure.
______________________________________________
___________________________
Signature of Employee or Employee’s Representative
Date
___________________________________________
_____________________________
Printed Name of Employee or Employee’s Representative
Relationship to Employee, or
Representative’s authority to act for
Employee, if applicable