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1. Parties: Identification of the employee (authorizing party), employer (receiving party), and healthcare provider(s) (releasing party)
2. Background: Brief context explaining the purpose of the authorization and the relationship between the parties
3. Definitions: Key terms used in the document including 'Medical Information', 'Healthcare Provider', 'Authorized Recipients'
4. Scope of Authorization: Specific description of what medical information is authorized for release, including time periods covered
5. Purpose of Disclosure: Clear statement of why the information is being released and how it will be used by the employer
6. Duration of Authorization: Specify how long the authorization remains valid and when it expires
7. Rights of Revocation: Statement of the employee's right to revoke the authorization and the process for doing so
8. Privacy and Confidentiality: Obligations of the employer regarding the protection and confidential handling of the medical information
9. Execution: Signature blocks for all parties and date of execution
1. Re-disclosure Provisions: Additional terms regarding whether and how the employer may share the information with other parties (include when information might need to be shared with other departments or external consultants)
2. State-Specific Provisions: Include when operating across multiple states to address specific state law requirements
3. Electronic Records Provision: Include when medical records may be transmitted or stored electronically
4. Translation Statement: Include when the employee's primary language is not English
5. Special Categories of Information: Include when authorization covers sensitive information like mental health, HIV status, or genetic information requiring specific consent
1. Schedule A - Specified Medical Information: Detailed list of specific medical information authorized for release
2. Schedule B - Authorized Healthcare Providers: List of healthcare providers authorized to release information
3. Schedule C - Authorized Employer Representatives: List of specific employer representatives authorized to receive and handle the medical information
4. Appendix 1 - Revocation Form: Standard form for revoking the authorization
Healthcare
Mining
Construction
Manufacturing
Transportation
Emergency Services
Aviation
Maritime
Education
Professional Services
Public Sector
Retail
Hospitality
Agriculture
Security Services
Human Resources
Occupational Health and Safety
Risk Management
Compliance
Workers Compensation
Employee Relations
Legal
Privacy and Data Protection
Operations
Medical Services
Human Resources Manager
Occupational Health and Safety Officer
Risk Manager
Compliance Officer
Workers Compensation Coordinator
Return to Work Coordinator
Employee Relations Manager
Workplace Health Manager
Operations Manager
Site Manager
Safety Director
Medical Review Officer
Privacy Officer
Legal Counsel
HR Business Partner
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