TR-0408 (Rev. 6/12) RDA-413
Page 2 of 2
Release Records To: TCRS and Representatives thereof
502 Deaderick Street
Nashville, Tennessee 37243-0201
Which Records? All medical, psychiatric, psychological diagnosis and treatment records, hospital
records and any records pertaining to my medical history, pathology, including tissue
samples, slides and/or blocks, charts and x-ray fi lm reports
Purpose of Disclosure: For use in pending application for disability retirement benefi ts
SECTION 3. PROVIDER AUTHORIZATION
I hereby authorize the healthcare provider(s) and its physicians, employees and agents listed within
this form to release or disclose to the Tennessee Consolidated Retirement System (TCRS) and its
representatives all of my medical records, including records pertaining to treatment, prognosis and
diagnosis, including any specially-protected or listed records, such as those relating to psychological or
psychiatric impairments, drug abuse, alcoholism, sickle cell anemia or HIV infection. I further authorize
the healthcare provider(s) and its physicians, employees and agents listed within this form to provide to
and discuss with
TCRS and its representatives any confi dential information with respect to my medical
condition or treatment, either formally or informally.
I understand that I may revoke the Authorization at any time prior to the expiration date or event, but that my
revocation will not have any effect on actions taken by the above-named healthcare provider(s) or its physicians,
employees or agents before the healthcare provider(s) received my revocation. Should I desire to revoke this
Authorization, I must send written notice to the healthcare provider(s). I understand that I am not required to sign
this Authorization. The above-named healthcare provider(s) will not condition treatment, payment, enrollment or
eligibility for benefi ts on whether I provide this Authorization. However, I further understand that if I do not sign
this Authorization, I may not be eligible to obtain disability retirement benefi ts from TCRS since TCRS must have
competent medical records to document that I am totally and permanently disabled from all substantial gainful
employment.
I understand that my records may be subject to disclosure by the recipient and may no longer be protected
by federal privacy regulations. I understand that this Authorization does not limit the above-named healthcare
provider(s) or its physicians’, employees’ or agents’ ability to use or disclose my information for treatment,
payment or healthcare operations, or as otherwise permitted by law. I further understand and acknowledge that
I am responsible for all costs associated with the provision of the information described herein to the TCRS.
Patient or Authorized Representative’s Signature
Relationship to Patient Date
THIS AUTHORIZATION WILL EXPIRE TWO YEARS AFTER THE DATE OF SIGNATURE ABOVE.
A PHOTOCOPY OF THIS AUTHORIZATION IS TO BE CONSIDERED AS VALID AS THE ORIGINAL.
