SOP_NUMBER: 104.21-att-3
TITLE: Authorization for Release of Medical Information
DIVISION: Administrative & Finance
TOPIC_AREA: 104 Policy-HR Programs/Support/Assistance
EFFECTIVE_DATE: 2017-04-25
WORD_COUNT: 187
POWERDMS_URL: https://public.powerdms.com/GADOC/documents/144395
URL: https://gps.press/sop-data/104.21-att-3/

SUMMARY:
This form authorizes GDC to obtain medical information from healthcare providers and treating physicians about an employee's medical history, psychiatric care, substance use, and medical conditions. The authorization is limited to the period of employment and requires that any medical information obtained by the employer be kept confidential and only released to authorized persons and entities as permitted by law. Photocopies of the signed form are valid for all purposes.

KEY_TOPICS: Medical information release, health care provider authorization, employee medical records, confidentiality, medical history, psychiatric records, substance abuse records, fitness for duty, employment authorization, HIPAA compliance

ATTACHMENTS:
  1. Equal Employment Opportunity Commission Poster
     URL: https://gps.press/sop-data/104.21-att-1/
  2. ADA Physician's Statement
     URL: https://gps.press/sop-data/104.21-att-2/
  3. Authorization for Release of Medical Information
     URL: https://gps.press/sop-data/104.21-att-3/

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FULL TEXT:
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SOP 104.21
Attachment 3

4/25/17

# **GEORGIA DEPARTMENT OF CORRECTIONS**


_**AUTHORIZATION FOR RELEASE OF MEDICAL INFORMATION**_


TO HEALTH CARE PROVIDERS & TREATING PHYSICIANS:

This authorizes you to give the official representatives of the Georgia Department of
Corrections (GDC) and its agents any information, data or records you have regarding my
medical history and/or treatment (including records pertaining to psychiatric, drug and
alcohol use, and any medical condition I may have or have had); and any information,
data or records pertaining to evaluations I have received, which are needed to assess my
fitness for performance of assigned duties, job functions, and work responsibilities.

This authorization is valid only during the period of my employment with GDC, and with
the knowledge and understanding that _any information obtained by my employer,_
_pertaining to my medical condition or history, must be kept confidential_ and may only be
released to specific persons and entities authorized by law.

For all purposes described herein, a photocopy of this authorization is as valid as the
original document.

**________________________________     __________________________________**
**Printed or Typed Name** **Employee Signature**

**________________________________     __________________________________**
**Social Security #** **Employee ID #**

**________________________________**
**Date**


Record Retention: Retain permanently in the employee’s local medical file.