Authorization to Release and Review Information
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This document is an authorization form that permits the Scranton Human Relations Commission to access, review, and copy medical information related to a complainant's civil rights discrimination case filed under the Scranton Human Relations Act. The form authorizes release of medical records including written reports on physical or mental condition and treatment, and permits the Commission to re-disclose the information without further authorization. The complainant is informed that provision of the information is voluntary but that refusal may result in dismissal of their complaint for lack of evidence or failure to cooperate. The authorization remains valid until the Commission closes the complaint unless the complainant provides written revocation beforehand.
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