The information which you provide on this form is being requested for the principal purpose of processing the release of your medical records.
Records: EHS Nurse records, EHS Medical records, Personal Physician's records pertinent to a Medical Condition, or Other.
Revoking: you may revoke this authorization by writing to the EHS Privacy Official unless the EHS has already released or disclosed the information.
Information: failure to provide the information requested may prevent your medical records from being released.
Re-disclosure: this information may be re-disclosed by the recipient and no longer be protected under federal law.
Copy: please make sure you receive a copy of this authorization after you sign it.
| Question | Answer |
|---|---|
| Form Name | EHS-742 |
| Form Length | 1 page |
| Fillable? | Yes |
| Fillable fields | 38 |
| Avg. time to fill out | 7 min |
| Edition | Rev 5/2026 |
| Expires | In 90 days or on the day you enter |
| Matches the agency's file | Yes, checked October 2, 2026 |
| Other names | EHS-742, EHS 742, EHS742, Form EHS-742, EHS medical records release, Authorization for Release and Disclosure of Medical Information |
| Official source | EHS-742 (Rev 5/2026), Employee Health Service |
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