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DHR EO 014 <br />(Re -issued: July 2018) <br />County of Hawaii <br />(Department/Agency) <br />AUTHORIZATION FOR RELEASE OF MEDICAL INFORMATION <br />I hereby request and authorize <br />(Medical Professional's Name) <br />(Medical Professional's Address) <br />(Medical Professional's Telephone No.) <br />to release and send to <br />Name, Job Title <br />Department <br />Address <br />Telephone <br />E-mail <br />the following information about me: <br />Note to Physician: I understand this information is to help determine the extent of <br />and severity of my impairment(s), and the effect of the impairment(s) on the <br />activities noted below: <br />o Access to facilities <br />o Performance of job duties, <br />o Adjustment(s) to the workplace, <br />o and/or modifications) to enable me to perform my job duties. <br />