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Disability Medical Release Form
"I need a Disability Medical Release Form that allows my employer and occupational health provider to access my medical records related to my mobility condition for the next 12 months, starting from January 2025, to arrange workplace accommodations."
1. Individual's Personal Information: Basic details including name, date of birth, address, and contact information
2. Medical Information Authorization: Specific authorization for release of medical information including scope and duration
3. Purpose of Release: Clear statement of why the medical information is being released
4. Recipients of Information: Details of who is authorized to receive the medical information
5. Data Protection Statement: Information about how data will be handled and protected
6. Signature Section: Space for signatures, dates, and witness information
1. Representative Authorization: Used when someone else is authorized to act on behalf of the individual - applicable when individual lacks capacity or chooses to delegate authority
2. Specific Exclusions: Details of any medical information specifically excluded from the release - used when individual wants to restrict certain information from being shared
3. Time Limitations: Specific time periods for which the release is valid - used when release should be limited to specific time period
1. Schedule A - Detailed Medical Records List: Itemized list of specific medical records to be released
2. Schedule B - Authorized Recipients: Detailed list of all authorized recipients and their contact information
3. Appendix 1 - Privacy Notice: Detailed privacy notice explaining data protection rights and procedures
4. Appendix 2 - Capacity Assessment: If relevant, documentation of capacity assessment
Authors
Confidential Medical Information
Data Protection Laws
Disability
Effective Date
Healthcare Provider
Individual
Legal Representative
Medical Records
Medical Release Authorization
Personal Data
Protected Health Information
Relevant Medical Information
Release Period
Sensitive Personal Data
Special Category Data
Specified Purpose
Third Party Recipients
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