Medical Release Form (Hearing) SAMPLE
About this document
This is a completed sample form which provides authorization to the Federal Motor Carrier Safety Administration to publish hearing exemption information in a public docket.
Federal Motor Carrier Safety Administration
AUTHORIZATION FOR RELEASE OF INFORMATION
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 X I do not authorize this information to be released.
Information Limitations, if any: (list any information you do NOT want to release)
This information may also be shared with (please check one of the following):
1. Legal Representative : (if you have a lawyer, put his/her name here)
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 am asking for an exemption from the hearing standard in CFR 49 391.41._I intend to drive in interstate commerce.
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.
Signing person Name, Address & Telephone #: Name(s) John Doe
123 Main Street, Dallas, TX 11111
Telephone # (and_email,applicable)
Request sent to:
1. Physician Company Person Other (explain)
2. Address: _
3. Phone Number: Fax #:
* Signature of Applicant Signing Person Legal Representative:
John D Doe______________________ Date: 1/2/2012 Relationship to applicant: (if someone other than you is signing on your behalf, they must list their relationship to you here)
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.