Community College District
Medical Authorization and Release
TO WHOM IT MAY CONCERN:Pursuant to my request for reasonable accommodation under the Americans with Disabilities Act and the Fair Employment and Housing Act, my employer is authorized to determine whether I have a physical or mental impairment which limits a major life activity, to determine what restrictions I have that impact the duties of my position, and to evaluate the effectiveness of possible reasonable accommodation.
I do hereby request that any information requested be provided as fully and completely as is reasonably possible.
I do hereby release and hold harmless you, your organization or company, your officers, agents, employees, or independent contractors from any liability or damages, and I do hereby waive all claims or causes of action against you, your organization or company, your officers, agents, employees or independent contractors, which may result from furnishing the requested information.
This authorization to release medical records will expire six (6 months) after the date signed. I have been advised that I have the right to receive a copy of this authorization.
Name (print): _____________________________________________________________________________________
DOB: ____________________________ SSN#: _________________________________________________________
Phone (w): (_______)______________________________________________________________________________
Phone (h): (_______)______________________________________________________________________________
Note to Employee: You are entitled to receive a copy of this authorization upon request.
AAO - 8 7/30/2003