If you own a business, there is a good chance you will need to submit an Ehs 742 form. This form is required by the Environmental Protection Agency (EPA) and is used to report information about hazardous materials. Completing this form can be complicated, so it is important to understand what information is required and how to submit it. In this blog post, we will provide an overview of the Ehs 742 form and explain how to complete it. We will also discuss some of the implications of submitting inaccurate information. If you have any questions, please contact us for assistance. Thank you for your interest in our blog!
| Question | Answer |
|---|---|
| Form Name | Ehs 742 Form |
| Form Length | 1 pages |
| Fillable? | No |
| Fillable fields | 0 |
| Avg. time to fill out | 15 sec |
| Other names | Cohoes, NY, NYS, form filling typing |
NYS Department of Civil Service
Employee Health Service
55 Mohawk Street - Suite 201
Cohoes, NY 12047
(518)
Authorization for Release and
Disclosure of Medical Information
(Please Print Clearly) |
INFORMATION CONCERNING |
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Last Name |
First Name |
M.I. |
Date of Birth
Social Security #
Street Address |
City |
State |
Zip Code |
Personal Privacy Protection Law - The information which you provide on this form is being requested pursuant to Section 82..3 of the Regulations of the Department of Civil Service (President's Regulations) for the principal purpose of processing the release of your medical records (4NYCRR 82.3). This information will be used in accordance with Section 96 (1) of the Personal Privacy Protection Law, particularly subdivisions (b), (e), and (f). Failure to provide the information requested may prevent your medical records from being released. This information will be maintained by the Administrator of the Employee Health Service, NYS Department of Civil Service, 55 Mohawk Street - Suite 201, Cohoes, NY 12047. For further information relating only to the Personal Privacy Protection Law, call (518)
AUTHORIZATION FOR RELEASE AND DISCLOSURE OF MEDICAL INFORMATION
I, ___________________________________________, authorize release or disclosure of the following medical records:
EHS Nurse records of: __________________________________________________________________________________
(Date(s)
EHS Medical records of:__________________________________________________________________________________
(Date(s)
Personal Physician's records pertinent to: _____________________________________________________________________
(Medical Condition)
Other _________________________________________________________________________________________________
THESE RECORDS WILL BE USED FOR:
My Personal Use |
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By EHS to Determine Your Ability to Perform the Duties of Your Position |
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____________________________________________________________ |
________________________________________ |
Signature |
Date |
This information may be
This authorization expires is 90 days or on:____________________________. You may revoke this authorization by writing to the EHS Privacy
Official at the address at the top of this page unless the EHS has already released or disclosed the information for the purpose(s) noted above. Please
make sure you receive a copy of this authorization after you sign it.
SEND RECORDS |
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SEND RECORDS |
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FROM: |
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TO: |
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Employee Health Service |
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Employee Health Service |
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NYS Department of Civil Service |
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NYS Department of Civil Service |
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55 Mohawk Street – Suite 201 |
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55 Mohawk Street – Suite 201 |
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Cohoes, NY 12047 |
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Cohoes, NY 12047 |
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Physician, Hospital, Other |
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Physician, Attorney, Self, Other |
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Organization |
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Organization |
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Street or PO Box |
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Street or PO Box |
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Zip Code |
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Copies: |
EHS (white) |
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EMPLOYEE (Pink) |
OTHER (Yellow) |
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