A document which authorizes his/her employer to release employment records including, but limited to, his/her employment history and wages and any information which may be requested relative to his/her employment, employment applications, and other related matters, and to furnish copies of any and all records which the employer may have regarding his/her employment.
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 records. 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 hereof. A copy of this authorization may be used in place of and with the same force and effect as the original. Dated: Print Name: Date of Birth Social Security Number Sworn to before me this ____ day of __________________, 20___. Notary Public
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