"Authorization Form for Review of Released Records and Information - State Employees' Leave Bank Program" - Maryland

Authorization Form for Review of Released Records and Information - State Employees' Leave Bank Program is a legal document that was released by the Maryland Department of Budget and Management - a government authority operating within Maryland.

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  • Released on April 1, 2018;
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STATE EMPLOYEES’ LEAVE BANK PROGRAM
AUTHORIZATION FORM FOR REVIEW OF RELEASED RECORDS AND INFORMATION
A. Identification: This document authorizes the use and/or disclosure of confidential protected health information
about the following person; this is not used to request medical records or information on the employee’s
behalf.
Employee’s Name: ______________________________________
Date of Birth: ___________________
B. Directions for Release:
I authorize the individual or company identified below in Section B.1b to release and/or use protected health
information pertaining to the individual listed in Section A to the individual(s) identified in Section B.1a.
B.1a.
I authorize the disclosure of information to:
o State Medical Director
o State Employees’ Leave Bank Program
B.1b.
I authorize the release of information from:
o (Specify Health Care Provider) _______________________________________________________
o State Medical Director
B.2.
Information to be released: I authorize the disclosure and/or use of any information from my
medical records relating to the condition(s) for which I am seeking leave.
B.3.
Purposes: I authorize the disclosure and/or use for the following reason(s):
(a) to determine my eligibility for leave from the State Employees’ Leave Bank Program
B.4.
I am asking that you NOT provide any genetic information when responding to this request for medical
information. Genetic information, as defined by the Genetic Information Nondiscrimination Act of 2008,
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.
C. Right to Revoke: I understand that I may revoke this authorization at any time except to the extent that action
has already been taken in reliance upon it. This authorization will expire one year after the date it is signed. To
revoke the authorization, I must contact, in writing: Jennifer Hine, Director, Personnel Services, Department of
Budget and Management, 301 W. Preston Street, Room 705, Baltimore, MD 21201 or via Fax at 410-333-5440.
D. Authorization and Signature: I authorize the review of my confidential protected health information, as
described in my directions in Section B. I understand that this authorization is voluntary, the information to be
disclosed is protected by law and the disclosure will conform with my directions. The information that is used
and/or disclosed pursuant to this authorization may be redisclosed by the recipient unless the recipient is
covered by Maryland law which prohibits redisclosure or other laws limiting the use and/or disclosure of my
confidential protected health information.
I have read the contents of this authorization and I confirm that the contents are consistent with my directions.
I understand that by signing this form, I am authorizing the review and/or disclosure of my confidential
protected health information.
________________________________
___________________
Employee Signature
Date
(Rev. 4/2018)
STATE EMPLOYEES’ LEAVE BANK PROGRAM
AUTHORIZATION FORM FOR REVIEW OF RELEASED RECORDS AND INFORMATION
A. Identification: This document authorizes the use and/or disclosure of confidential protected health information
about the following person; this is not used to request medical records or information on the employee’s
behalf.
Employee’s Name: ______________________________________
Date of Birth: ___________________
B. Directions for Release:
I authorize the individual or company identified below in Section B.1b to release and/or use protected health
information pertaining to the individual listed in Section A to the individual(s) identified in Section B.1a.
B.1a.
I authorize the disclosure of information to:
o State Medical Director
o State Employees’ Leave Bank Program
B.1b.
I authorize the release of information from:
o (Specify Health Care Provider) _______________________________________________________
o State Medical Director
B.2.
Information to be released: I authorize the disclosure and/or use of any information from my
medical records relating to the condition(s) for which I am seeking leave.
B.3.
Purposes: I authorize the disclosure and/or use for the following reason(s):
(a) to determine my eligibility for leave from the State Employees’ Leave Bank Program
B.4.
I am asking that you NOT provide any genetic information when responding to this request for medical
information. Genetic information, as defined by the Genetic Information Nondiscrimination Act of 2008,
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.
C. Right to Revoke: I understand that I may revoke this authorization at any time except to the extent that action
has already been taken in reliance upon it. This authorization will expire one year after the date it is signed. To
revoke the authorization, I must contact, in writing: Jennifer Hine, Director, Personnel Services, Department of
Budget and Management, 301 W. Preston Street, Room 705, Baltimore, MD 21201 or via Fax at 410-333-5440.
D. Authorization and Signature: I authorize the review of my confidential protected health information, as
described in my directions in Section B. I understand that this authorization is voluntary, the information to be
disclosed is protected by law and the disclosure will conform with my directions. The information that is used
and/or disclosed pursuant to this authorization may be redisclosed by the recipient unless the recipient is
covered by Maryland law which prohibits redisclosure or other laws limiting the use and/or disclosure of my
confidential protected health information.
I have read the contents of this authorization and I confirm that the contents are consistent with my directions.
I understand that by signing this form, I am authorizing the review and/or disclosure of my confidential
protected health information.
________________________________
___________________
Employee Signature
Date
(Rev. 4/2018)