3.930 RCUH Safety & Accident Prevention Program
Attachment 2
RCUH Form B-4
Created 12/16/1993 (Revised 09/01/2002, 10/16/2013)
RESEARCH CORPORATION OF THE UNIVERSITY OF HAWAII
EMPLOYEE/CLAIMANT CONSENT FORM
TO: RCUH Director of Human Resources
I, , hereby authorize my physician, hospital,
clinic, insurance company or other institution or person to permit the bearer of this
consent form or the Research Corporation of the University of Hawaii (RCUH), or its
authorized representatives, claims adjusters, and insurance representatives to receive
clarification on any medical information provided to by a certified/authorized medical
practitioner, view, copy or be furnished copies of any and all medical information,
including x-rays, relating to (check appropriate box):
Processing/Administration of my Industrial Accident and related Workers
Compensation benefits (this authorization allows release and access to
treatments rendered to me for my injury/illness; includes results of psychiatric/
psychological and substance abuse testing, and as applicable prior medical history
related to this injury/illness).
Post offer/Periodic Physical Examination
Medical Certification required by RCUH policy (Sick Leave, JPA, LTDI, etc.)
I understand that this authorization is for a specific time period (not to exceed the time
necessary to process the action checked above) and may be revoked at anytime in
writing. I understand this authorization is specifically for the processing of the purpose
stated above.
Contact Information of Physician: Please PRINT legibly.
I agree that a copy of this authorization bears the same authority as the original.
_________________________________________ ________________
Signature of Employee/Claimant Date
The Genetic Information Nondiscrimination Act of 2008 ("GINA") prohibits employers and other entities covered by GINA Title II from requesting or
requiring genetic information of an individual or family member of the individual, except as specifically allowed by this law. To comply with this law, we
are asking that you not provide any genetic information when responding to this request for medical information. "Genetic Information" as defined by
GINA includes an individual's family medical history, the results of an individual's or family member's genetic tests, the fact that an individual or an
individual's family member sought or received genetic services, and genetic information of a fetus carried by an individual or an individual's family
member or an embryo lawfully held by an individual or family member receiving assistive reproductive services
