Page 34 - DIDC SOPS and Guidelinesv as of April 2019

Patient Social Security Number

AUTHORIZATION FOR RELEASE OF INFORMATION FROM MEDICAL RECORD

Record Subject
(Patient's Name) Last Name First Name Middle Initial Birthday or Age

Address
Street, City and State Telephone Number

I, the undersigned, hereby authorize Occu-Med – 2121 West Bullard Avenue, Fresno, CA 93711
Health Care or Health Services Provider

to provide from my medical record the information specified below to:

• DynCorp International – 1700 Old Meadow Road, McLean, VA 22102;
• CenterScope Technologies – 7900 Westpark Drive, Suite T220, McLean VA 22102;
• USARCENT / USCENTCOM; and,
• Other:

for the purpose of evaluating my health status in relation to essential job requirements and USCENTCOM
MOD 12 Deployment Guidelines. [Note: Information will only be submitted to USARCENT or
USCENTCOM to assess your compliance with USCENTCOM MOD 12 Deployment Guidelines, when
indicated.]

The information supplied is to be restricted to information collected or provided during this
deployment evaluation process.

Release or transfer of the specified information to any person or entity not specified herein is prohibited.
An additional written consent must be obtained for a proposed new use of the information or for its
transfer to another person or entity.

This authorization shall be valid until (or until revoked)
Date

Date of revocation
Date

Signature
Social Security Number Date

or
Personal Representative Date

2121 West Bullard Avenue, Fresno, CA 93711 559.435.2800 fx:800.262.2863