Release for Employment Records - DOC - DOC by ReadyBuiltForms


A document that provides a release for an employer to release an employees records

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									                         AUTHORIZATION AND RELEASE FOR
                             EMPLOYMENT RECORDS

       I hereby authorize my Employer to release to ________________ and its agents,
copies of any and all records in your possession relating in any way to employment and/or
health, including by way of example, but not limited to the following:

         Applications for employment, records of all positions held, performance
         evaluations and reports, statements and comments of fellow employees, attendance
         records, all physician, hospital, medical, psychiatric and health reports, x-rays, test
         results, physical examinations, any records relating to claims made relating to
         health, disability or accidents in which she was involved, including
         correspondence, reports, claim forms, questionnaires, records of payments made to
         to physicians, hospitals and health institutions or professionals, any statements of
         account, bills or invoices, any workers' compensation claims, including claim
         petitions, judgments, physician, hospital and medical records, records of payments
         made, investigatory reports and records, and any all other records.

       This authorization also includes the authority to copy and inspect any and all such

        This authorization is continuing in nature and is to be given full force and effect to
release any and all of the foregoing information learned or determined after the date

        A copy of this authorization may be used in place of and with the same force and
effect as the original.

                                                     Print Name:

Date of Birth

Social Security Number

         Sworn to before me this ____ day of __________________, 20___.

                                                     Notary Public

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