TEANECK BOARD OF EDUCATION HUMAN RESOURCE MANAGEMENT

EMPLOYEE AUTHORIZATION TO RELEASE/DISCLOSE

INFORMATION TO THE TEANECK BOARD OF EDUCATION.

I, _______________________________, authorize the Office of the Human Resource Management of the Teaneck Board of Education to speak with and disclose information and records to my doctor concerning the information contained herein, for purposes of seeking clarification of the information that has been provided. I similarly authorize my doctor, ______________________, to speak with and disclose information and records to the Teaneck Board of Education.

I understand that I have the right to revoke this authorization at any time. I understand if I revoke this authorization, I must do so in writing and present my written revocation to the Office of Human Resource Management of the Teaneck Board of Education. I understand that his revocation will not apply to information that has already been released in response to this authorization.

This authorization shall expire on June 30, 2021.

Employee Signature: ___________________________________ Date: __________________