Permission to Release Medical Information by jrGFi7h

VIEWS: 4 PAGES: 1

									         PERMISSION TO RELEASE MEDICAL INFORMATION



By my signature on this document, I give permission to

(name of personal physician) to release medical information

to the following authorized agency officials, (identify the

specific officials who will have access to the medical

information), in order to respond to my request for

reasonable accommodation.




Signature:   _________________________ Date:   ______________




                                    Attachment 2 (Encl (2))

								
To top