What is Afmes Form 1323? As an employer, you may be wondering what this form is and how it applies to your business. Afmes Form 1323 is the Authorization for Release of Medical Information form. This form allows employers to release employee medical information to insurance providers or other designated third parties. It's important to note that the authorization must be in writing and signed by the employee before any medical information can be released. Employers are responsible for ensuring that all necessary information is included on the form, including contact information for both the employee and the recipient of the information. Any questions about filling out Afmes Form 1323 should be directed to your nearest HR office.
| Question | Answer |
|---|---|
| Form Name | Afmes Form 1323 |
| Form Length | 1 pages |
| Fillable? | No |
| Fillable fields | 0 |
| Avg. time to fill out | 15 sec |
| Other names | afmes, TOXICOLOGICAL, afmes form 18 fillable pdf, EDITIONS |
AFMES/ DIVISION OF FORENSIC TOXICOLOGY - TOXICOLOGICAL REQUEST FORM
TO:
FORWARD FINAL REPORT TO: (Please use complete mailing address)
EMAIL ADDRESS:
NAME OF PATIENT (Last, First, MI)
SOCIAL SECURITY #
AGE
SEX
RACE
DATE OF INCIDENT/ ACCIDENT
TIME AND DATE OF DEATH
AUTOPSY #
MEDICATION HISTORY (Prescribed or administered, in patient’s possession, containers found near body, etc.)
SPECIMEN/ AMOUNT |
SPECIMEN/ AMOUNT |
SPECIMEN/ AMOUNT |
1. |
5. |
9. |
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2. |
6. |
10. |
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3. |
7. |
11. |
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4. |
8. |
12. |
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INCIDENT/ ACCIDENT DETAILS (Include pertinent information regarding crash site, autopsy or investigation; (e.g., What happened?)
PRINTED NAME OF REQUESTER/ TITLE |
SIGNATURE |
DATE |
TELEPHONE #: |
|
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COMM: ( |
) |
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DSN: |
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FAX: |
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CHAIN OF CUSTODY (CC)
Each individual charged with custody of specimens must complete information below (continue CC on reverse as required).
RELEASED BY |
RECEIVED BY |
DATE & TIME |
PURPOSE OF TRANSFER |
SIGNATURE
SIGNATURE
PRINTED NAME
PRINTED NAME
SIGNATURE
SIGNATURE
PRINTED NAME
PRINTED NAME
SIGNATURE
SIGNATURE
PRINTED NAME
PRINTED NAME
SIGNATURE
SIGNATURE
PRINTED NAME
PRINTED NAME
SIGNATURE
SIGNATURE
PRINTED NAME
PRINTED NAME
AFMES FORM 1323, NOV 2011 PREVIOUS EDITIONS OBSOLETE.