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Medical Release, HIPPA Form

I am requesting the release of my medical records:

Employee Name

to the Central New York Universal Life Church. From:

Name and Address of Medical Provider or Facility

Information to be shared with the church

Purpose of Release

Starting Date of Request

Ending Date (If Known) otherwise this will expire one year after signing.

Disclaimers: You may revoke this authorization at any time. Please send a written notification to the HR Team. Your notice will not apply to actions taken by parties before your revocation date. You may inspect or copy the protected health information to be used or disclosed under this authorization. If the receiving party is not a healthcare provider or health plan covered by federal privacy regulations, the information sent may be disclosed to parties who are not bound by healthcare regulations. The church will follow its confidentiality policy. You may refuse to sign this authorization. Your refusal to sign may affect your ability to obtain any leave requested by the church; it will not affect your ability to receive treatment, payment, or eligibility for benefits beyond a denial of leave.