Authorization for Examination and Release of Final Opinion for Fitness for Duty
I hereby authorize the offices of ________________________, to conduct an employment-related fitness for duty examination because I have been ordered to submit to such an examination by my employer, the _________________________________.
In conjunction with this examination, I hereby authorize ________________________ to review relevant medical and employment records supplied by my employer to the extent that I have authorized their release to the examining doctor. All other prior or contemporaneous authorizations which are inconsistent with this authorization have been or are hereby rescinded. I DO NOT authorize the release of my medical, psychiatric and employment records after they have been reviewed for any reason.
I authorize ___________________________________ to provide my employer, ___________________________, with ONLY a final opinion concerning whether or not I am "fit for duty." This opinion may may be made in writing by letter to my employer, with a copy to be concurrently mailed to me. I have not placed my medical or psychological condition at issue by filing a workers compensation claim, or if one has been filed, it has been retracted prior to this examination.
[OPTIONAL: I further authorize __________________________ to inform my employer whether the condition upon which the final opinion is based is work-related.]
[OPTIONAL: What are the physical limitations on my ability to perform the duties of a peace officer.]
[OPTIONAL: What is the estimated duration of my inability to perform my regular duties if your final opinion hat I am NOT fit for duty.]
Any medical records, statements or other information or documents that may be utilized or generated as a result of this examination shall be used only for the purposes of this fitness for duty evaluation and shall not be released to anyone, including my employer.
Release of any information, other than a final opinion will be considered a violation of my right to privacy and a violation of the Confidentiality of Medical Records Act (Civil Code §56 et seq.).
Date: ________________
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________________________________________ Patient's Signature ________________________________________ ________________________________________ |