Subpart Z
No — the sample authorization letter in 1910.1020 App A is non-mandatory and provided only as a model to help employers and employees craft an authorization. See 1910.1020 App A and the main 1910.1020 standard for the regulatory requirements employers must follow.
The sample shows that either the employee or the employee's legal representative may sign the authorization letter. The form includes a line for the "Full name of Employee or Legal Representative" and a signature and date line. See 1910.1020 App A and the related 1910.1020 standard.
The authorization should describe generally the medical information you want released — the sample includes a blank space labeled "Describe generally the information desired to be released." Use plain, specific wording so it is clear which records are covered. See the model in 1910.1020 App A and consult 1910.1020 for how employee medical records are addressed.
Yes — the sample explicitly lets the employee state the permitted purpose and prohibits other uses or re‑disclosure by saying, "I give my permission for this medical information to be used for the following purpose... but I do not give permission for any other use or re-disclosure of this information." Clearly state the allowed purpose on the form. See 1910.1020 App A and 1910.1020.
Yes — the sample specifically notes that you may "describe medical information to be created in the future that you intend to be covered by this authorization letter." If you want future medical records included, state that on the form. See 1910.1020 App A and the main 1910.1020.
It is good practice to include an expiration date; the sample suggests you "may want to specify a particular expiration date for this letter (if less than one year)." The model encourages you to state an expiration if you want limits on how long the authorization lasts. See 1910.1020 App A and consult 1910.1020 for general record access requirements.
Yes — the sample includes several extra blank lines and explicitly states you may place additional restrictions on the authorization (for example, limiting redisclosure, specifying an expiration, or excluding parts of the record). Use those lines to state any conditions you want. See 1910.1020 App A and 1910.1020.
Yes — the sample form includes lines for the "Signature of Employee or Legal Representative" and the "Date of Signature," indicating that a signed and dated authorization is expected in the model. See 1910.1020 App A and the 1910.1020 standard for context.
Yes — the sample explicitly provides for either the "Employee or Legal Representative" to print their full name and sign, so a legal representative may sign if they are authorized to act for the employee. See 1910.1020 App A and 1910.1020.
Yes — the sample is drafted to authorize "(individual or organization holding the medical records) to release to (individual or organization authorized to receive the medical information)" the specified medical information, i.e., it authorizes release to a designated recipient. See 1910.1020 App A and the 1910.1020 standard.
Yes — the sample explicitly says you may "describe portions of the medical information in your records which you do not intend to be released as a result of this letter," so you can identify and exclude specific portions. See 1910.1020 App A and 1910.1020.
No — the sample does not establish a default expiration date; it only notes you "may want to (1) specify a particular expiration date for this letter (if less than one year)." If you want a time limit, include one on the form. See 1910.1020 App A and 1910.1020.
No — the sample authorization does not include a notarization or witness block; it simply provides lines for printed name, signature, and date. If notarization is required by other laws or by the records-holder's policy, that would be handled separately. See 1910.1020 App A and 1910.1020.
The sample does not include a specific revocation clause, but it provides extra lines for additional restrictions or terms — you can add revocation language on those lines to state how and when the authorization can be revoked. See 1910.1020 App A and consult 1910.1020 for related record-access rules.
Yes — the sample is written so the employee names the "individual or organization holding the medical records" (for example, an employer medical clinic or an outside provider) and authorizes that holder to release the records to the designated recipient. See 1910.1020 App A and 1910.1020.
Yes — the sample asks you to state the purpose for which the information may be used, so you can list a specific purpose such as a workers' compensation claim and prohibit other uses or redisclosure. See 1910.1020 App A and 1910.1020.
Yes — the sample is provided as a model authorization that an employee or legal representative can sign to allow the records-holder to release medical records to a designated representative; employers can use or adapt the model to document a valid authorization. See 1910.1020 App A and make sure actual releases comply with the 1910.1020 record-access requirements.
If the authorization is vague, request clarification or a revised authorization that clearly describes the records and purpose; the sample emphasizes a general description of the information to be released so the holder and recipient know the scope. See 1910.1020 App A and consult 1910.1020 to ensure compliance with employee record‑access rules.