SECTION 1 – Medical Provider/Patient Information
Date:
To:
Medical Provider Name
Medical Provider Address
City	State	Zip Code
Medical Provider Fax Number
Reference:
Patient Name	Patient Date of Birth
Patient Address
City	State	Zip Code
SECTION 2 – Authorization
I authorize [Name of Healthcare Provider] to disclose to [Name of Return-to-Work Coordinator or designee]or any other person, including the agency’s legal counsel, who is authorized by my employer to receive medical information that is specifically related and necessary to determine whether I have a disability and whether accommodations can be made. I also authorize [Name of Return-to-Work Coordinator or designee], or others as listed above, to speak to my treating health care provider directly in regards to any questions with respect to my condition as it relates to the performance of the essential functions of my job and any accommodations that may be necessary. I understand that the requested data is for the above-mentioned purposes only, and that I may refuse to provide the requested medical information. However, I understand that if I refuse to provide this information, my employer may refuse to provide reasonable accommodations. I also understand that this information shall remain confidential, available only under limited conditions specified under law. This authorization is valid for one year from the date indicated below or upon receipt of my signed written notice to withdraw my consent. A photocopy is as valid as an original.
Patient Name (Print)	Patient Signature	Date