Health Information Release Waiver
for ADA Accommodations
Name (Please Print)
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
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