Environmental Health & Safety	E H & S TEL NO: (818) 677-2401 FAX NO: (818) 677-5853 MAIL DROP: 8284
	Authorization for Release of Medical Records Information

I,	(Full name of Employee/Patient)
hereby authorize	(Individual/Organization Holding Medical Records) ,
to release to	(Individual/Organization Authorized to Receive Medical Record Information),
the following medical information from my personal Medical Records:

I. Describe generally the information to be released:

II. I give my permission for this medical information to be used for the following purpose:

III. I DO NOT give my permission for any other use or re-disclosure of this information

Employee or Legal Representative Signature: _______________________________________

Print Full Name of Employee or Legal Representative:

Date: ___________________