San Francisco Community College District
(CONFIDENTIAL)

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 hereby authorize and direct you, your office/practice, its Custodian of Records and/or person in your employ to release medical information relating to my request for reasonable accommodation to my employer, in the format of the Health Care Provider Certification Form provided by my employer (pursuant to the Medical Confidentiality Act, Civil Code Section 56, et seq.).  This medical information may be released to any authorized representative of the San Francisco Community College District bearing this release or a photocopy thereof, in order to evaluate my request for 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#: _________________________________________________________

Address: ________________________________________________________________________________________

Phone (w): (_______)______________________________________________________________________________

Phone (h): (_______)______________________________________________________________________________

Class/Title ______________________________________________________________________________________

Department:_____________________________________________________________________________________
 

Signature:_________________________________________________________________ Date:_________________

Note to Employee: You are entitled to receive a copy of this authorization upon request.

AAO - 8 7/30/2003