Appendix A to §1910.1020—Sample authorization letter for the release of employee medical record information to a designated representative (non-mandatory)

I, _____________________ (full name of worker/patient) hereby authorize _______ (individual or organization holding the medical records) to release to _____________________ (individual or organization authorized to receive the medical information), the following medical information from my personal medical records:
_________________________________
_________________________________
(Describe generally the information desired to be released).

I give my permission for this medical information to be used for the following purpose: ________________ but I
________________ do not give permission for any other use or re-disclosure of this information.