DEPARTMENT OF HEALTH & HUMAN SERVICES Federal Occupational Health Service Medical Employability Program

 FAX: 301-594-3321

 Email: Medical.Employability@foh.hhs.gov

AUTHORIZATION FOR DISCLOSURE OF INFORMATION

(Pursuant To The Privacy Act of 1974, 5 U.S.C. 552a, 29 CFR 1910.1020, and 42 CFR Part 2)

(The release of information about a patient who is treated or referred for treatment for alcohol or drug abuse, or the medical results of such abuse, is governed by the 

Confidentiality of Alcohol and Drug Abuse Patient Record Regulations, 42 CFR Part 2).

 TO: Treating Medical Care Provider

 ______________________________________________ _______________________________

 (name) (phone)

 ______________________________________________ _______________________________

 (address) (fax) 

 ____________________________________________________ _________________ ___________________ 

 (City) ( State) (ZIP) 

You are hereby authorized to furnish information from the record of the individual named below which is in the record system of your facility, and release it t

MEP Medical Director or Designate

Federal Occupational Health

Medical Employability Program

1. Name of EMPLOYEE (print or type)

2. Agency

Department of Homeland Security - Federal Law Enforcement Training Centers (DHS FLETC Glynco)

3. Purpose or need for the disclosure (please check)

 COMPENSATION CLAIM(S)

 LEGAL

 REASONABLE ACCOMMODATION

 SICK LEAVE, FAMILY MEDICAL LEAVE 

 OTHER ______________________________

4. Specify extent and nature of information to be disclosed for each purpose or need

indicated, and SPECIFY inclusive dates:

from______________________________ to____________________________

The Federal Occupational Health is requesting medical information supporting the 

employee’s request for sick leave, Family Medical Leave (FMLA), accommodation 

under the Rehabilitation Act, or other personnel benefits. Information discussed is to be 

confidential. In cases where the individual may require first aid/emergency treatment, or 

if government officials are investigating compliance with the ADAAA, relevant 

information may be shared, as required by law. 

This authorization is subject to revocation at any time except to the extent that DFOH or the other program specified which is to make the disclosure has already taken 

action in reliance on it. If this authorization has not been revoked otherwise, it will expire upon the termination of the interagency agreement that authorized the 

services provided by Federal Occupational Health for the subject individual’s federal employer.

Any person who knowingly and willfully requests or obtains any record concerning an individual from a Federal agency under false pretenses shall be guilty of a 

misdemeanor and fined not more than $ 5,000 (5 U.S.C 552a(i)(3)); in the case of alcohol and drug abuse patient records, a falsified authorization for disclosure is 

prohibited under 42 CFR 2.31 and is punishable by a fine of not more than $500 for a first offense or a fine of not more than $5,000 for a subsequent offense, in 

accordance with 42 CFR 2.4.

5. Print Name of PATIENT: 6. If other than subject, indicate relationship or authority: ____________________________

7. Date of signature: _____________________ 8. Date of Birth: ____________________

9. Last four of SSN: __________

10. Kaiser-Permanente Number (if applicable): ___________________________________

11. Signature of PATIENT: 12. Signature of Parent/Guardian/Power of Attorney.

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The Medical Employability Program will only utilize a signed “Authorization for Release of Information” for a period 

of six (6) Months from the date of signature.