Attachment 4 "Authorization for Release of Medical Information in Reference to the Americans With Disabilities Act" - Florida

What Is Attachment 4?

This is a legal form that was released by the Florida Department of Juvenile Justice - a government authority operating within Florida. As of today, no separate filing guidelines for the form are provided by the issuing department.

Form Details:

  • Released on August 17, 2011;
  • The latest edition provided by the Florida Department of Juvenile Justice;
  • Easy to use and ready to print;
  • Quick to customize;
  • Compatible with most PDF-viewing applications;
  • Fill out the form in our online filing application.

Download a fillable version of Attachment 4 by clicking the link below or browse more documents and templates provided by the Florida Department of Juvenile Justice.

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Download Attachment 4 "Authorization for Release of Medical Information in Reference to the Americans With Disabilities Act" - Florida

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Attachment 4
FDJJ 1060 – 4
New 8/17/11
FLORIDA DEPARTMENT OF JUVENILE JUSTICE
AUTHORIZATION FOR RELEASE OF MEDICAL INFORMATION
IN REFERENCE TO THE AMERICANS WITH DISABILITIES ACT
By signing this form, the employee grants permission to the physician or health care provider listed below
to release the referenced medical information to the authorized DJJ representative. This information is to
be used only for determining reasonable accommodation(s), in accordance with the provisions of the
Americans with Disability Act, for the named employee.
Date:
Employee’s Name:
Employee’s Business Address:
City:
State:
Zip Code:
Employee’s Business Telephone Number:
Name of Physician or Health Care Provider:
Address of Physician or Health Care Provider
Telephone Number of Physician or Health Care Provider:
I,
, hereby authorize the above named physician or health care provider
to release the following information to the authorized representative of the Florida Department of
Juvenile Justice listed below. This request does not include “Genetic Information” as defined below:
Agency’s Authorized Representative
Title
Phone
Employee’s Signature
Title
Phone
The Genetic Information Nondiscrimination Act of 2008 (GINA) prohibits employers and others entities covered by GINA Title II from
requesting or requiring genetic information of an individual or family member of the individual, except as specifically allowed by this
law. To comply with this law, we are asking that you not provide any genetic information when responding to this request for
medical information. “Genetic Information”, as defined by GINA, includes an individual’s family medical history, the results of an
individual’s or family member’s genetic tests, the fact that an individual or an individual’s family member sought or received genetic
services, and genetic information of a fetus carried by an individual or an individual’s family member or an embryo lawfully held by
an individual or family member receiving assistive reproductive services.”
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Attachment 4
FDJJ 1060 – 4
New 8/17/11
FLORIDA DEPARTMENT OF JUVENILE JUSTICE
AUTHORIZATION FOR RELEASE OF MEDICAL INFORMATION
IN REFERENCE TO THE AMERICANS WITH DISABILITIES ACT
By signing this form, the employee grants permission to the physician or health care provider listed below
to release the referenced medical information to the authorized DJJ representative. This information is to
be used only for determining reasonable accommodation(s), in accordance with the provisions of the
Americans with Disability Act, for the named employee.
Date:
Employee’s Name:
Employee’s Business Address:
City:
State:
Zip Code:
Employee’s Business Telephone Number:
Name of Physician or Health Care Provider:
Address of Physician or Health Care Provider
Telephone Number of Physician or Health Care Provider:
I,
, hereby authorize the above named physician or health care provider
to release the following information to the authorized representative of the Florida Department of
Juvenile Justice listed below. This request does not include “Genetic Information” as defined below:
Agency’s Authorized Representative
Title
Phone
Employee’s Signature
Title
Phone
The Genetic Information Nondiscrimination Act of 2008 (GINA) prohibits employers and others entities covered by GINA Title II from
requesting or requiring genetic information of an individual or family member of the individual, except as specifically allowed by this
law. To comply with this law, we are asking that you not provide any genetic information when responding to this request for
medical information. “Genetic Information”, as defined by GINA, includes an individual’s family medical history, the results of an
individual’s or family member’s genetic tests, the fact that an individual or an individual’s family member sought or received genetic
services, and genetic information of a fetus carried by an individual or an individual’s family member or an embryo lawfully held by
an individual or family member receiving assistive reproductive services.”
Save As
Reset/Clear Form
Print Form
Email Form