This information is provided free of charge by the Department of Industrial Relations from its web site at www.dir.ca.gov. These regulations are for the convenience of the user and no representation or warranty is made that the information is current or accurate. See full disclaimer at http://www.dir.ca.gov/od_pub/disclaimer.html.

Subchapter 7. General Industry Safety Orders
Group 1. General Physical Conditions and Structures Orders
Introduction

Return to index
New query

§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

Go BackGo Back to General Industry Safety Orders, Introduction