• Step 2 of 2: HIPAA Authorization For Use Or Disclosure Of Health Information

    This form is for use when such authorization is required and complies with the Health Insurance Portability and Accountability Act of 1996 (HIPAA) Privacy Standards. 

  • IMPORTANT: If you have not completed Step 1: Admission Registration,
    please click here to fill out the form.

  • Date of Birth*
     - -
  • Have you completed the HIPAA Security Training?*

  • 1. My Authorization

  • I authorize the following party: ATLANTA MEDICAL TESTING SERVICES, LLC, to use or disclose the following health information required to begin training with the Atlanta CDL Training School. (check all that apply)

  • I Authorize the following:*

  • The above party may disclose this health information to the following recipient:

    Organization: ATLANTA CDL TRAINING SCHOOL

    Address: 2952 Moreland Ave. Suite 3000, Conley, Georgia, 30288

    Phone: Tel: (678) 400-7812

    Email: results@atlantacdltrainingschool.com 

  • The purpose of this authorization is: (check all that apply)

  • Authorization Purpose:*

  • 2. My Rights

  • I understand that I have the right to revoke this authorization, in writing, at any time, except where uses or disclosures have already been made based upon my original permission. I may not be able to revoke this authorization if its purpose was to obtain insurance. In order to revoke this authorization, I must do so in writing and send it to the appropriate disclosing party.

    I understand that uses and disclosures already made based upon my original permission cannot be taken back.
    I understand that it is possible that information used or disclosed with my permission may be redisclosed by the recipient and is no longer protected by the HIPAA Privacy Standards.

    I will receive a copy of this authorization after I have signed it.

    A copy of this authorization is as valid as the original.

  • Date*
     - -

  • 3. Additional Consent for certain conditions: This medical record may contain information about alcoholism, drug abuse, or mental health treatment. 

  • Separate consent must be given before this information can be released:*
  • Date*
     - -

  • For official guidelines: https://www.fmcsa.dot.gov/regulations/drug-alcohol-testing/overview-drug-and-alcohol-rules. https://www.fmcsa.dot.gov/regulations/medical

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