Health Information Release Waiver
for ADA Accommodations
Name (Please Print)
Address
City
State
Zip Code
Work Phone Number
Home Phone Number
I, _______________________________________________________, am requesting
reasonable accommodations for my medical condition(s) through my employer, Albany
State University. I give a Human Resources Department representative permission to
speak with and/or request written information regarding medical assessment(s) on my
behalf. I authorize my health care provider to release relevant information regarding my
medical condition. I realize that this information will be kept in confidence and will be
used only for purposes of approval of reasonable accommodations under the
Americans with Disabilities Act (ADA).
Employee Signature
click to sign
signature
click to edit
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