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Get NY CS EHS-742 6/06 2006-2024

NYS Department of Civil Service Employee Health Service 55 Mohawk Street - Suite 201 Cohoes NY 12047 518 233-3100 Authorization for Release and Disclosure of Medical Information EHS-742 6/06 Please Print Clearly INFORMATION CONCERNING Last Name First Name Street Address M. Failure to provide the information requested may prevent your medical records from being released. This information will be maintained by the Administrator of the Employee Health Service NYS Department of Civil Service 55 Mohawk Street Suite 201 Cohoes NY 12047. For further information relating only to the Personal Privacy Protection Law call 518 457-2487. For information concerning this form please contact the Employee Health Service at 518 233-3100. AUTHORIZATION FOR RELEASE AND DISCLOSURE OF MEDICAL INFORMATION I authorize release or disclosure of the following medical records EHS Nurse records of Date s EHS Medical records of Personal Physician s records pertinent to Medical Condition Other THESE RECORDS WILL BE USED FOR My Personal Use By EHS to Determine Your Ability to Perform the Duties of Your Position Signature This information may be re-disclosed by the recipient and no longer be protected under federal law. I. Date of Birth City Social Security State Zip Code Personal Privacy Protection Law - The information which you provide on this form is being requested pursuant to Section 82. 3 of the Regulations of the Department of Civil Service President s Regulations for the principal purpose of processing the release of your medical records 4NYCRR 82. 3. This information will be used in accordance with Section 96 1 of the Personal Privacy Protection Law particularly subdivisions b e and f. Failure to provide the information requested may prevent your medical records from being released* This information will be maintained by the Administrator of the Employee Health Service NYS Department of Civil Service 55 Mohawk Street Suite 201 Cohoes NY 12047. For further information relating only to the Personal Privacy Protection Law call 518 457-2487. For information concerning this form please contact the Employee Health Service at 518 233-3100. AUTHORIZATION FOR RELEASE AND DISCLOSURE OF MEDICAL INFORMATION I authorize release or disclosure of the following medical records EHS Nurse records of Date s EHS Medical records of Personal Physician s records pertinent to Medical Condition Other THESE RECORDS WILL BE USED FOR My Personal Use By EHS to Determine Your Ability to Perform the Duties of Your Position Signature This information may be re-disclosed by the recipient and no longer be protected under federal law. This authorization expires is 90 days or on. You may revoke this authorization by writing to the EHS Privacy Official at the address at the top of this page unless the EHS has already released or disclosed the information for the purpose s noted above. Please make sure you receive a copy of this authorization after you sign it. SEND RECORDS FROM TO Physician Hospital Other Physician Attorney Self Other Name Organization Street or PO Box Copies EHS white EMPLOYEE Pink OTHER Yellow. .

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