AUTHORIZATION OF RELEASE OF PERSONAL AND MEDICAL INFORMATION
I, the undersigned, hereby authorize and medical information to Facilities currently contacted with for the purpose of verifying that I meet the requirements specified In the Employee/ Applicant
The use of the information supplied is to be restricted to the foregoing stated verification.
The release or transfer the specified information to any person or entity not specified herein is prohibited. An additional written consent must be obtained for a proposed new use of the Information or for Its transfer to another or entity.
Unless otherwise stated or mandated by law, this release of information consent form will not expire.