Consent to Release Occupational Health Report

Please fill in the form below and submit it.

A copy of this form will be sent to the email address you submit.

Medical reports for insurance and or employment purposes – including occupational health reports – are covered by the Access to Medical Reports Act (1988). GMC updated guidance on medical confidentiality, with specific reference to occupational health, was released in April 2017.

I confirm the OH Practitioner has discussed the outcome report/ their professional opinion with me.(Required)

Confirm

Consent to Report (to be completed at the end of your appointment).

Copy of report(Required)

I want a copy of the report at the same time it is sent (to employer) by email

I want a copy of the report at the same time it is sent (to employer) by post

Employee’s email address to which to which copy of report is to be sent.(Required)

Your email address(Required)

You will have 5 working days, following receipt of the draft report to request any factual changes (you cannot request any changes to the clinician’s professional opinion). You will have one opportunity to request any factual changes. If we do not hear from you by the end of the 5 working days we will advise your employer that the report cannot be sent to you until you confirm you have withdrawn consent for its release.

Copy of report before it is sent(Required)

I do not want a copy of the report

Send by email

Sent by post

Postal address to which copy of report is to be sent(Required)

Street Address Address Line 2 City County / State / Region Postcode

Withdrawal of Consent In accordance with the Access to Medical Reports Act (1988) you can withdraw your consent at any time, even if it has previously been granted.

I withdraw consent to the release of an occupational health report to my Employer.

I understand that my Employer will only receive a statement that the appointment has been attended and that I have withdrawn consent for release of a report. I understand that my Employer may then make decisions without the benefit of specialist OH advice which may not be in my best interest.

Signature

For use if you have a touchscreen enabled device

Name / Signature(Required)

Date(Required)

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