[{"data":1,"prerenderedAt":-1},["ShallowReactive",2],{"doc-seo-195375-105":3,"detail-sidebar-cat-1-en-105":85,"doc-detail-195375-en":131},{"code":4,"msg":5,"data":6},0,"ok",{"site_id":7,"language":8,"slug":9,"title":10,"keywords":11,"description":12,"schema_data":13,"social_meta":78,"head_meta":80,"extra_data":82,"updated_unix":84},105,"en","medical-clearance-release-form","Medical Clearance Release Form","","This document is a Medical Clearance Release Form that allows an individual to authorize the Office of Medical Clearances to share their medical and mental health information with designated individuals. The form outlines the patient's understanding of their right to privacy, the voluntary nature of signing the release, and the potential risks associated with electronic communication. It specifies who can receive the information, the methods of communication (in person, phone, fax, mail, e-mail), and the expiration date of the release. The form also includes sections for reaffirmation and extension of the release, signed by the individual and a witness. It is crucial that the user understands that signing this form is completely voluntary and does not affect their clearance status. Future releases will require a new, time-limited written release. The form emphasizes that once information is released, the Office of Medical Clearances may not be able to control its subsequent use or disclosure.",{"@graph":14,"@context":77},[15,34,56],{"@type":16,"itemListElement":17},"BreadcrumbList",[18,23,27,31],{"item":19,"name":20,"@type":21,"position":22},"https://docshare.wps.com","Home","ListItem",1,{"item":24,"name":25,"@type":21,"position":26},"https://docshare.wps.com/template/","Template",2,{"item":28,"name":29,"@type":21,"position":30},"https://docshare.wps.com/template/forms/","Forms",3,{"item":32,"name":10,"@type":21,"position":33},"https://docshare.wps.com/template/medical-clearance-release-form/195375/",4,{"url":32,"name":10,"@type":35,"image":36,"author":41,"headline":10,"publisher":44,"fileFormat":47,"inLanguage":8,"description":12,"dateModified":48,"datePublished":49,"encodingFormat":47,"isAccessibleForFree":50,"interactionStatistic":51},"DigitalDocument",{"url":37,"@type":38,"width":39,"height":40},"https://docshare.wps.com/thumbnails/medical-clearance-release-form/195375.png","ImageObject",442,249,{"name":42,"@type":43},"Patrick","Person",{"url":19,"name":45,"@type":46},"DocShare","Organization","application/pdf","2026-10-02","2026-09-03",true,{"@type":52,"interactionType":53,"userInteractionCount":55},"InteractionCounter",{"@type":54},"ViewAction",7,{"@type":57,"mainEntity":58},"FAQPage",[59,65,69,73],{"name":60,"@type":61,"acceptedAnswer":62},"What is the purpose of this Medical Clearance Release Form?","Question",{"text":63,"@type":64},"This form allows individuals to authorize the Office of Medical Clearances to share their medical and mental health information with specific individuals they designate.","Answer",{"name":66,"@type":61,"acceptedAnswer":67},"Is signing this release form mandatory?",{"text":68,"@type":64},"No, signing this release form is completely voluntary. Failure to sign will not affect your clearance status, and you can choose not to allow the release of your information.",{"name":70,"@type":61,"acceptedAnswer":71},"What are the different ways medical information can be shared?",{"text":72,"@type":64},"Medical information can be shared in person, by phone, by fax, by mail, or by e-mail. The form explicitly warns that e-mail is not confidential and can be intercepted.",{"name":74,"@type":61,"acceptedAnswer":75},"How long is this release valid?",{"text":76,"@type":64},"This release is valid from the time it is signed until the specified expiration date and time. It can be withdrawn at any time either orally or in writing. An optional section allows for reaffirmation and extension of the release.","https://schema.org",{"og:url":32,"og:type":79,"og:title":10,"og:site_name":45,"og:description":12},"article",{"robots":81,"canonical":32},"index,follow",{"doc_id":83,"site_id":7},195375,1788447975,{"code":4,"msg":86,"data":87},"success",[88,93,98,103,108,113,117,122,127],{"id":89,"doc_module":22,"doc_module_name":25,"category_name":90,"show_sort_weight":91,"slug":92},11,"Presentations",90,"presentations",{"id":94,"doc_module":22,"doc_module_name":25,"category_name":95,"show_sort_weight":96,"slug":97},12,"Resumes",80,"resumes",{"id":99,"doc_module":22,"doc_module_name":25,"category_name":100,"show_sort_weight":101,"slug":102},14,"Invoices",70,"invoices",{"id":104,"doc_module":22,"doc_module_name":25,"category_name":105,"show_sort_weight":106,"slug":107},15,"Posters",60,"posters",{"id":109,"doc_module":22,"doc_module_name":25,"category_name":110,"show_sort_weight":111,"slug":112},16,"Social Media",50,"social-media",{"id":114,"doc_module":22,"doc_module_name":25,"category_name":29,"show_sort_weight":115,"slug":116},17,40,"forms",{"id":118,"doc_module":22,"doc_module_name":25,"category_name":119,"show_sort_weight":120,"slug":121},18,"Letters",30,"letters",{"id":123,"doc_module":22,"doc_module_name":25,"category_name":124,"show_sort_weight":125,"slug":126},21,"Paper Templates",5,"papers-templates",{"id":128,"doc_module":22,"doc_module_name":25,"category_name":129,"show_sort_weight":4,"slug":130},158,"General","general-158",{"code":4,"msg":86,"data":132},{"doc_id":83,"user_id":133,"nickname":42,"user_avatar":134,"doc_module":22,"category_id":114,"category_name":29,"doc_title":10,"doc_description":12,"doc_content":135,"file_id":136,"file_url":137,"file_type":138,"file_size":139,"view_count":55,"is_deleted":4,"is_public":22,"is_downloadable":22,"audit_status":22,"page_count":22,"language":140,"language_code":8,"site_id":7,"html_lang":8,"table_of_contents":141,"faqs":142,"seo_title":143,"seo_description":12,"update_tm":84,"read_time":4},549758146520,"https://ap-avatar.wpscdn.com/avatar/80002397d8c0411e94?_k=1775819394049821470","| I understand that the Office of Medical Clearances has an obligation to keep my personally identifiable information, including medical records, confidential. I also understand that I can choose to allow the Office of Medical Clearances to release medical and mental health aspects of my personal information to certain individuals. I understand that failure to sign this form will not affect my clearance status.\u003Cbr>I,   , MED ID Number   authorize the Office of Medical Clearances to share my medical clearance reports, labs and information needs with:\u003Cbr>Who I want to have my information:\u003Cbr>Name (Last, First, MI) ~~ ~~ ~~ ~~ ~~ ~~\u003Cbr>Relationship  \u003Cbr>Phone Number  \u003Cbr>The information may be shared (Please check all that apply) :\u003Cbr> In Person  By Phone  By Fax  By Mail  By E-Mail\u003Cbr> I understand that electronic mail (e-mail) is not confidential and can be intercepted and read by other people.\u003Cbr>\u003Cbr>Please check the boxes below to indicate that you understand:\u003Cbr> That I do not have to sign a release form. I do not have to allow the Office of Medial Clearances to share my information. Signing a release form is completely voluntary. If I would like Medical Clearances to release information about me in the future, I will need to sign another written, time-limited release.\u003Cbr> That Medical Clearances may not be able to control what happens to my information once it has been released to the above person. This release expires on  Date (mm-dd-yyyy)  ~~ ~~Time~~ ~~\u003Cbr>I understand that this release is valid when I sign it and that I may withdraw my consent to this release at any time either orally or in writing.\u003Cbr>Printed Name |  |\n| --- | --- |\n| Signature | Date (mm-dd-yyyy) |\n| Witness  \u003Cbr>Reaffirmation and Extension (if additional time is necessary to meet the purpose of this release) I confirm that this release is still valid, and I would like to extend the release until\u003Cbr>New Date (mm-dd-yyyy) New Time |  |\n| Signature | Date (mm-dd-yyyy) |\n| Witness\u003Cbr>|  |","cbCainaxUFUXSvKc","https://ap.wps.com/l/cbCainaxUFUXSvKc","pdf",51770,"English","# Medical Clearance Release Form\n## Patient Information and Authorization\n## Information Sharing Preferences\n## Understanding and Consent\n## Reaffirmation and Extension","[{\"question\":\"What is the purpose of this Medical Clearance Release Form?\",\"answer\":\"This form allows individuals to authorize the Office of Medical Clearances to share their medical and mental health information with specific individuals they designate.\"},{\"question\":\"Is signing this release form mandatory?\",\"answer\":\"No, signing this release form is completely voluntary. Failure to sign will not affect your clearance status, and you can choose not to allow the release of your information.\"},{\"question\":\"What are the different ways medical information can be shared?\",\"answer\":\"Medical information can be shared in person, by phone, by fax, by mail, or by e-mail. The form explicitly warns that e-mail is not confidential and can be intercepted.\"},{\"question\":\"How long is this release valid?\",\"answer\":\"This release is valid from the time it is signed until the specified expiration date and time. It can be withdrawn at any time either orally or in writing. An optional section allows for reaffirmation and extension of the release.\"}]","Medical Clearance Release Form | PDF"]