Orange County NC Website
Browse       Search
DocuSign Envelope ID:6E9B5308-6677-4F2E-9268-29D6E1A4FD76 <br /> CONFIDENTIAL <br /> i <br /> k <br /> AUTHORIZATION FOR THE RELEASE OF MEDICAL <br /> INFORMATION PURSUANT TO REQUEST <br /> i <br /> FOR REASONABLE ACCOMMODATION <br /> r <br /> f <br /> Name of License Physician or Practitioner Licensed Physician Phone(OPTIONAL) <br /> Name of Office,Clinic,Hospital,etc. Medical Number <br /> Street Address Requestor's Social Security Number <br /> City,State,Zip Requestor's Birth Date <br /> i <br /> TO: Any licensed physician,other licensed practitioner,hospital,clinic or other Medically-related facility,or United States Veterans <br /> Administration that there is in the possession of medical records pertaining to: <br /> NAME OF EMPLOYEE: <br /> (Please Print) <br /> I have requested that my employer, , grant me reasonable E <br /> accommodation due to my diagnosed physical or mental impairment of: <br /> i <br /> I authorize you to copy and transmit to the Reasonable Accommodation Coordinator of the Department of <br /> General Services all records concerning the above-referenced impairment and to answer any <br /> questions related to this condition. A copy of my request for reasonable accommodation is i <br /> attached to this release. <br /> The authorization shall be valid for a period of 180 days after the date of my signature or <br /> earlier if revoked by me in writing to the Reasonable Accommodation Coordinator. <br /> k <br /> I hereby acknowledge I have been informed of my right to receive a copy of this i <br /> authorization upon request. I further acknowledge I have been informed if the medical <br /> information covered herein is not release, my request for accommodation may be denied. <br /> r <br /> i <br /> Signature <br /> Date <br /> 107351.vl <br /> E <br /> is <br />