Labor & Industries (L&I), Washington State

Employee Medical and Exposure Records Chapter 296-802, WAC

Effective Date: 08/01/04

Helpful Tool: Sample: Authorization Letter for Release of Medical Information

For printing

Use with Employee Medical and Exposure Records, Chapter 296-802 WAC

I, ____________________________________(Employee or employee’s legal representative)

hereby authorize ____________________________________ (Name of employer) to release to

____________________________ (Individual or organization authorized to receive the medical

information) the following information from my personal medical records:

________________________________________________________________________________
(Specify the information to be released) ______________________________________________
________________________________________________________________________________

I give my permission for this medical information to be used only for the following purposes:

_______________________________________________________________________________
(Specify any conditions for release of medical information)______________________________
_______________________________________________________________________________

This authorization will expire in 90 days from date of signature unless a shorter period is designated.

Alternate expiration date (less than 90 days) _________________________________________

________________________________________
Full Name of Employee or Legal Representative

________________________________________
Signature of Employee or Legal Representative

_________________________________________
Date of Signature