Release of Employee Record Form

* = Required Information

Release of Employee Record Information to a Designated Representative

I (employee) ,herby authorize Elohim Medical Staffing Agency, Inc. to release to any client that might accept assignment for, the following information from any employment records.

Describe Record to be Released

Medical file, criminal Background check, HepB decline, CPR, BCLS, licenses,

I give my permission for medical information to be used for the following purposes(S): Release of Information to the employee and facility approval

I do not give permission for any other use or disclosure of this information.

Date

Print Full Name of Employee*

Print Full Name of Legal Representative