OCCUPATIONAL HEALTH SERVICE AUTHORIZATION

Form must be filled out in full for all Occupational Health visits. Completed forms can be: sent with employee or provided prior via fax (920-623-1286) or online.

Download the   PDF version here.

Reason
Employee Information
Persons/Organizations Authorized to Disclose

 

Patient's Health Information:
Name and address of service provider: 





Prairie Ridge Health

1515 Park Avenue

Columbus, WI 53925

Person(s)/Organization(s) Authorized to Receive Patient's Health Information*:
Person(s)/Organization(s) Responsible for Billing*:
Health Information to be disclosed:
Check applicable information.
Lab Alcohol and Drug Testing
Additional Lab Services
Vaccinations
Respiratory Therapy
Audiology
Occupational Health
DOT Physical
Purpose of Disclosure: Employment Requirements
YOUR RIGHTS WITH RESPECT TO THIS AUTHORIZATION:

i. Right to Inspect or Copy: I understand that I have the right to inspect or copy the health information I have authorized to be used or disclosed by this Authorization.

ii. Right to Receive Copy of Authorization: I understand that if I agree to sign this Authorization, which I a.m. not required to do, I will be provided with a signed copy of this Authorization.

iii. Right to Refuse to Sign Authorization: I understand that this Authorization is voluntary and that I may refuse to sign this Authorization. Unless allowed by law, my refusal to sign this Authorization will not affect my ability to obtain treatment from Prairie Ridge Health (“PRH”). However, I also understand that the occupational health services that I receive from PRH are provided for the purpose of disclosing the results to my employer or other third party. Refusal to sign this Authorization may result in a refusal by PRH to provide me with the specific occupational health services (non-treatment related) that have been requested.

iv. Right to Revoke Authorization: I understand that written notification must be presented to PRH to cancel this Authorization. I understand that my withdrawal will not be effective as to uses and/or disclosures of health information already made in reliance on this Authorization.



Note: The occupational health services that you receive from Prairie Ridge Health, Inc. ("PRH") are provided for the purpose of disclosing the results to your employer or other third party. Refusal to sign this Authorization may result in a refusal by PRH to provide you with the specific occupational health services (non-treatment related) that have been requested.

* REDISCLOSURE NOTICE: I understand that if the person(s)/organization(s) listed on this form are not governed by Federal privacy laws, the health information disclosed as a result of this Authorization may be re-disclosed by the recipient and no longer be protected by such laws.

Signature

I have had an opportunity to review and understand the content of this Authorization. By signing this Authorization, I a.m. confirming that it accurately reflects my wishes.

Signature must be in-person--please download and print page 2.

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