Hearing Packet

Company
This field is for validation purposes and should be left unchanged.
Release of Medical Information
Employee Name*
First Last
Date of Birth*
MM slash DD slash YYYY
Gender*
- Male
- Female
- Prefer not to answer
SS#*
Employee ID*
Address*
Street Address City State ZIP Code
County*
Cell Phone*
Text Message Consent*
- I consent to receive updates via text message.
- I do not consent to receive updates via text message.
Personal Email*

Your Results may be sent to you by email. Please provide an email for which you can receive your results. Most company firewalls will block outside e-mails, please provide a personal email address.
Employer*
Employer Address*
Street Address City State / Province / Region ZIP / Postal Code
Company Contact Person*
Company Contact Phone*
- This authorization shall expire one year after my employment ceases.
- I may revoke this authorization in writing by contacting your office at the above address.
- I understand that I may periodically be asked to update this Medical Release Form at the discretion of Alliance Health Resources Mobile Division, Ltd.
- I understand that my authorization provided means that the authorized organization can disclose, communicate or send my protected health information to the organization, entity or person identified above, including through the use of electronic means.
Signature*

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