Authorization to Disclose Employment Information

AUTHORIZATION TO DISCLOSE EMPLOYMENT INFORMATION

I, ______, date of birth , social security no. ______authorize the disclosure by ______to Wm. Bruce Hemphill, Esquire, 136B East Main Street, Elkton, Maryland 21921, or any representative thereof, information relative to my personnel file to include, but not limited to employment and payroll information.

Wm. Bruce Hemphill has been retained by me to investigate and if warranted initiate and pursue to a conclusion a legal claim for personal injuries sustained by me against individuals, entities or insurers responsible therefore and your full cooperation with them is respectfully requested. You are further advised to disclose no information to any insurance adjuster or other persons without written authority from me to do so (pursuant to privilege and confidential communication laws including but not limited to the provisions of HIPAA) with the exception of persons, insurers or entities from whom you receive a written authorization signed by me that is in compliance with Section 164.508 of HIPAA.

I understand I have the right to revoke this authorization at any time. I understand if I revoke this authorization I must do so in writing and present my written revocation to the health information management department. I understand the revocation will not apply to information that has already been released in response to this authorization. I understand the revocation will not apply to my insurance company when the law provides my insurer with the right to contest a claim under my policy. Unless otherwise revoked, this authorization will expire on the following date, event or condition: . If I fail to specify an expiration date, event or condition, this authorization will expire in six months.

I understand that authorizing the disclosure of this payroll information is voluntary. I can refuse to sign this authorization. I understand I may inspect or copy the information to be used or disclosed, as provided in CFR 164.524. I understand any disclosure of information carries with it the potential for an unauthorized re-disclosure and the information may not be protected by federal confidentiality rules.

Date:______Name