A
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B
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C
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D
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E
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F
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G
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H
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I
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J
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K
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L
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M
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N
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O
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P
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Q
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R
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S
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T
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U
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X
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Y
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OTHER
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Directory Results for I, (patient, parent, legal guardian), (print name), hereby to I, (patient/employee), hereby authorize you, (physician/practitioner), to release the personal health ination requested on the attached Fitness for Duty Evaluation form to my employer, so that my employer can assess my ability to

I, (patient, parent, legal guardian), (print name), hereby
I, (patient/employee), hereby authorize you, (physician/practitioner), to release the personal health ination requested on the attached Fitness for Duty Evaluation form to my employer, so that my employer can assess my ability to