About this document

This form provides authorization to the Federal Motor Carrier Safety Administration to publish hearing or seizure exemption information in a public docket.

FMCSA
Federal Motor Carrier Safety Administration
www.fmcsa.dot.gov

AUTHORIZATION FOR RELEASE OF INFORMATION

APPLICANT IDENTIFICATION

Name:

Date of Birth:

Protected Health Information: Any information that can be linked back to the individual applicant, can be in any form: written, electronic, or verbal.

(Signed original will be placed in the applicant’s record and a copy provided to the applicant)

I     (NAME OF APPLICANT) authorize the Federal Motor Carrier Safety Administration (“FMCSA” or “the Agency”) to disclose, in a public docket accessible to all interested parties via the Internet, medical records and information related to my application for an exemption from one or more of the physical qualifications standards under 49 CFR 391.41. I understand that the medical records and information that will be disclosed by the Agency may include specific health information related to the medical conditions or illnesses, injuries, diagnosis, prognosis and medical treatment provided to me which have resulted in my not being able to obtain a medical certificate to operate commercial motor vehicles in interstate commerce. I understand that the American Health Insurance Portability and Accountability Act of 1996 (HIPAA) provides certain protections against the release of my personal medical records and information and hereby waive all protections provided by HIPAA with regard to medical records and information related to my application for an exemption from certain requirements under 49 CFR 391.41.

Please check and initial the statement that applies:  I do     I do not        authorize this information to be released.

Information Limitations, if any:      

This information may also be shared with (please check one of the following):

1.  Legal Representative       

2  Other (please specify):

Please note this document has two pages, you are required to read and complete information on both documents, the last page will require your complete signature first/last name and date.
 
Description of the exemption being sought and the medical information to be released to FMCSA in support of the exemption application, including the healthcare professionals responsible for providing the records that will be released.

I understand that I may refuse to sign this authorization and that my refusal to sign may affect my ability to obtain an exemption with the FMCSA. I understand that I may withdraw my application for an exemption at any time and that I may revoke this authorization in writing at any time prior to the FMCSA publishing a notice in the Federal Register soliciting public comments on my exemption application. I understand that after FMCSA publishes a notice in the Federal Register all medical records and information submitted to FMCSA will be submitted to a public docket accessible by all interested parties via the Internet. The Agency will not remove information from the public docket after it has been posted.

□ Applicant's Address  Signing person Name, Address & Telephone #:

Name(s)      

Address      

Telephone #       

Request sent to:

1.     Physician  Company  Person  Other (explain)

2.    Address:      

3.    Phone Number:    Fax #:      

*  Signature of Applicant  Signing Person  Legal Representative:

       Date:       

Relationship to applicant:      

All Facilities/persons listed on pages 1, 2 of this form may share information among and between themselves for the FMCSA assessment and Quality Assurance. Please sign above to authorize.