A common form for employees to fill out is the Arons authorization form. This form is used to request specific time off from work. The most common use of this form is when an employee needs to take a day off for a personal reason. There are several things that you should keep in mind when filling out this form. First, be sure to list the dates that you will be absent. Second, include the name and contact information of your supervisor. Finally, indicate the reason for your absence. By following these guidelines, you can help ensure that your request is processed quickly and efficiently.
Question | Answer |
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Form Name | Arons Authorizations Form |
Form Length | 1 pages |
Fillable? | No |
Fillable fields | 0 |
Avg. time to fill out | 15 sec |
Other names | aron authorization, arons authorization, interview permitted pdf, arons authorization pdf |
AUTHORIZATION TO PERMIT INTERVIEW OF TREATING PHYSICIAN BY DEFENSE COUNSEL
TO:
Physician’s name and address
You are hereby authorized to discuss certain medical condition(s) involving:
with
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Patient’s name |
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who is an attorney |
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Defense Attorney’s Name and Address |
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representing |
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in a |
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Defendant’s name |
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Type of Lawsuit |
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brought by |
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against |
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Plaintiff(s) Name |
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Defendant(s) |
The lawsuit is currently pending and is at
Stage of Proceeding
YOU ARE PERMITTED TO DISCUSS ONLY THE FOLLOWING MEDICAL CONDITIONS WHICH ARE THE SUBJECT MATTER OF THE AFOREMENTIONED LAWSUIT:
1.NOTHING CONTAINED HEREIN AUTHORIZES YOU TO DISCUSS ANYTHING ABOUT THIS PATIENT OTHER THAN THE
2.THE PURPOSE OF THIS INTERVIEW IS TO ASSIST THE DEFENDANT(S) IN THE DEFENSE OF THIS LAWSUIT BROUGHT BY THIS PATIENT. THIS AUTHORIZATION IS NOT AT THE REQUEST OF YOUR PATIENT.
3.YOUR WILLINGNESS TO PARTICIPATE IN THIS INTERVIEW IS ENTIRELY VOLUNTARY. YOU ARE FREE TO DECLINE THE REQUEST FOR SAID INTERVIEW.
4.You are permitted to disclose information relating to ALCOHOL and DRUG ABUSE, MENTAL HEALTH TREATMENT, except
psychotherapy notes, and CONFIDENTIAL HIV RELATED INFORMATION only if specifically initialed below:
(Indicate by Initialing): |
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Alcohol/Drug Treatment; |
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Mental Health Information; |
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5.If I am authorizing the release of
6.I have the right to revoke this authorization at any time by writing to the health care provider listed. I understand that I may revoke this authorization except to the extent that action has already been taken based on this authorization.
7.I understand that signing this authorization is voluntary. My treatment, payment, enrollment in a health plan, or eligibility for benefits will not be conditioned upon my authorization of this disclosure.
8.Information disclosed under this authorization might be redisclosed by the recipient (except as noted in Item 5 above), and this redisclosure may no longer be protected by federal or state law.
9.If not the patient, name of person signing form:
10.Authority to sign on behalf of patient:
11.Date this authorization will expire:
Signature |
Date |