AMAS

AMAS FAA Medical Release Form


The following medical release form is to be utilized by all Aviation Medicine Advisory Service (AMAS) clients to authorize communications between AMAS and the FAA. Airmen and controllers would write in the names of anyone in addition to the FAA with whom they would like to allow AMAS to discuss their particular case such as treating physician, spouses, union reps, etc.

The electronic submission allows you to type, draw, or upload a signature.  For some browsers you may need to clear cookies in order to clear the form.  If experiencing trouble using the electronic submission, you can download the release, manually sign and date, and send to our office by navigating back to the main menu and selecting the “PDF Download” option.

 

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 Federal Aviation Administration (FAA) medical representatives. I also authorize representatives of the FAA to release PHI to representatives of AMAS. This disclosure is at my request. AMAS may communicate PHI to them or me by telephone, voice messaging systems and non-secure email. Additionally, AMAS may disclose PHI to the following individuals and/or organizations specified below:

 

AMAS may discuss my case with the FAA and the following individuals/groups:

 

1.  

2.  

 

This authorization permits AMAS to use and/or disclose the following individually identifiable health information about me: all medical records in written form, including mental health and psychotherapy notes (if applicable), and all additional materials provided by me or by my treating health care providers to AMAS. FAA medical 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 obtaining FAA medical qualification determinations, though AMAS does not guarantee FAA decisions either expressed or implied.

Additional purposes of these disclosures may include determination of eligibility for Disability and Loss of License insurance benefits, Department of Labor / OWCP 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 three (3) years from the date listed below. I have the right to revoke this authorization at any time except to the extent that the practice has acted in reliance upon this 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 the FAA or other outside agencies, individuals, companies or organizations. When my information is used or disclosed pursuant to this authorization, it may be subject to redisclosure by the recipient and may no longer be protected by AMAS Privacy Policies.

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.

Today’s Date: 

Date of Birth:   / /  

Signature Certificate
Document name: AMAS FAA Medical Release Form
Unique Document ID: e019e8a8a9b4b2c5d8d86129828ce74d6c3c2f5a
Timestamp Audit
2015-10-22 15:25:47 MDTAMAS FAA Medical Release Form Uploaded by Aviation Doctors Advisory Services - Doctors@aviationmedicine.com IP 103.232.230.13