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AMAS HIMS/SSRI Program Medical Release

The following general medical release form is to be utilized by all Aviation Medicine Advisory Service (AMAS) clients. This form is to be used when providing release to AMAS to discuss their particular case with other clinical providers, attorneys, union or company representatives and all others outside of the FAA (not including the FAA).

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Patient Authorization for Use and Disclosure of Protected Health Information

By signing, I authorize Aviation Medicine Advisory Service (AMAS) and its staff to use and/or disclose certain protected health information (PHI) about me to the below named individuals/groups for purposes related to my participation in the HIMS Program and/or SSRI Program, IMS monitoring and my medical certification. This disclosure is at my request. AMAS may communicate PHI to them or me by telephone, voice messaging systems and non-secure email.

Section 1 – AMAS may discuss my case with the following individuals/groups:

Any physician, healthcare professional or counselor required for my participation in the HIMS and/or SSRI Program
Laboratory administrators for Soberlink, Affinity or any other laboratory used in conjunction with the HIMS and/or SSRI Program
Company Leave & Benefits representatives and other Company representatives involved in my HIMS and/or SSRI Program participation
Union representatives
Disability insurance carrier; Harvey Watt or other disability insurance carrier
Any treatment center or aftercare provider required for my participation in HIMS program (HIMS Program Only)

This authorization permits AMAS to use and/or disclose the following individually identifiable health information about me: all medical records in written form, substance abuse evaluations (SAE), mental health and psychotherapy notes (if applicable), and all additional materials provided by me or by my treating health care providers to AMAS. Treating providers and/or Union representatives and other individuals/entities listed by me above may release the above information to representatives of AMAS.

The primary purpose of these disclosures is to facilitate AMAS advice regarding medical certification, protect individual privacy, and promote aviation safety. AMAS will interpret clinical results to determine if I am safe to return to work or not. Additional purposes of these disclosures may include determination of eligibility for Disability and Loss of License insurance benefits, communicating with healthcare personnel in providing appropriate medical evaluations and treatment and contributing to my care, facilitating union officials in providing representation rights with my employer and for my employer to make a return to work determination. The purposes are provided so that I can make an informed decision whether to allow release of the information. This authorization will expire when I am no longer a participant in the HIMS or SSRI Program. I have the right to revoke this authorization at any time by sending written notice to AMAS. However, I understand that a revocation is not effective to the extent that any person or entity has already acted in reliance on my authorization.

AMAS will not receive payment or other remuneration from a 3rd party in exchange for using or disclosing the PHI. AMAS will not release, sell, or otherwise distribute any email addresses or personal contact information to any individual, company or organization for marketing purposes or secondary distribution.

I have had the opportunity to view the Notice of Privacy Policies that is posted at www.AviationMedicine.com (printed copy available upon request).

I do not have to sign this authorization in order to receive FAA Medical Certification advice from AMAS. In fact, I have the right to refuse to sign this authorization. Refusal to sign this authorization will prevent AMAS and its physicians from acting on the individual’s behalf with other outside agencies, individuals, companies or organizations. When my information is used or disclosed pursuant to this authorization, it may be subject to re-disclosure by the recipient and may no longer be protected by AMAS Privacy Policies.

I understand that AMAS will retain PHI and other information about me in its files in accordance with AMAS’s Document Retention and Destruction Policy.

Notice to Recipient of Medical Records and Protected Health Information sent by Aviation Medicine Advisory Service:

This Protected Health Information has been disclosed to you from confidential records. There is no intent, either expressed or implied, that you may make further distribution of this information without the specific written consent of the undersigned.

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Timestamp

Audit

May 16, 2023 10:29 am MDT

AMAS HIMS/SSRI Program Medical Release Uploaded by IMS Records - imsrecords@aviationmedicine.com IP 50.37.162.4

May 22, 2023 1:17 pm MDT