This release expires on
The information may be shared (Please check all that apply) :
Reaffirmation and Extension (if additional time is necessary to meet the purpose of this release) I confirm that this release is still valid, and I would like
to extend the release until
U.S. Department of State
Office of Medical Services
RELEASE OF MEDICAL INFORMATION
I, , MED ID Number
authorize the Office of Medical Clearances to
share my medical clearance reports, labs and information needs with:
Name (Last, First, MI)
In Person
By Phone By Fax
By Mail
By E-Mail
I understand that electronic mail (e-mail) is not confidential and can be intercepted and read by other people.
That I do not have to sign a release form. I do not have to allow the Office of Medial Clearances to share my information. Signing a release
form is completely voluntary. If I would like Medical Clearances to release information about me in the future, I will need to sign another written,
time-limited release.
Please check the boxes below to indicate that you understand:
That Medical Clearances may not be able to control what happens to my information once it has been released to the above person.
Date (mm-dd-yyyy)
Time
I understand that this release is valid when I sign it and that I may withdraw my consent to this release at any time either orally or in writing.
Printed Name
New Date (mm-dd-yyyy) New Time
Witness
Witness
DS-6563
05-2015
I understand that the Office of Medical Clearances has an obligation to keep my personally identifiable information, including medical records,
confidential. I also understand that I can choose to allow the Office of Medical Clearances to release medical and mental health aspects of my personal
information to certain individuals. I understand that failure to sign this form will not affect my clearance status.
Who I want to have my information:
Relationship
Phone Number
Signature
Date (mm-dd-yyyy)
Signature
Date (mm-dd-yyyy)
click to sign
signature
click to edit
click to sign
signature
click to edit
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