Get Authorization For Use, Disclosure Or Release Of ... - Purdue University - Purdue

This guide provides a clear, step-by-step approach to completing the Authorization For Use, Disclosure Or Release Of ... form from Purdue University. It aims to help users navigate the requirements for disclosing medical records related to evaluations under the Americans with Disabilities Act.

Follow the steps to fill out the form accurately and efficiently.

1. Click the ‘Get Form’ button to obtain the form and open it in your preferred document editor.
2. Enter the employee’s name in the designated field. Ensure to write the full name as it appears in official documentation.
3. Provide the employee’s address, including street, city, state, and zip code. Double-check for accuracy to avoid any delays.
4. Fill in the phone number field, ensuring it is a current number where the employee can be reached.
5. Identify the recipient of the medical records or health information. Specify the name of the office or individual who will receive the information.
6. Clearly describe the specific medical records or health information to be used or released. Be comprehensive to ensure that all required information is included.
7. Acknowledge the authorization of psychiatric and mental health information, if applicable, by confirming understanding of the regulations surrounding it.
8. Indicate understanding of re-disclosure risks by reviewing the statements regarding potential loss of protection after records are shared.
9. Confirm that signing the authorization does not impact treatment or benefits, reinforcing the employee's rights regarding their medical records.
10. Specify the expiration date for the authorization, selecting between the two set durations or providing an alternative date if desired.
11. Sign the form, ensuring that the employee’s signature is clear and legible, and include the date of signing.
12. If applicable, indicate whether the employee has declined a copy of this form by marking the appropriate checkbox.
13. After completing the form, users can save changes, download, print, or share the document as needed.

Take the first step towards managing your documents online by filling out the Authorization For Use, Disclosure Or Release Of ... form today.