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months prior to the disposal of the records.

(4) Where an employer regularly disposes of records required to be preserved for at least thirty (30)
years, the employer may, with at least (3) months notice, notify the Director of NIOSH on an annual
basis of the records intended to be disposed of in the coming year.

(i) Appendices.
The information contained in appendices A and B to this section is not intended, by itself, to create
any additional obligations not otherwise imposed by this section nor detract from any existing obligation.

APPENDIX A TO 1910.1020 - SAMPLE AUTHORIZATION LETTER FOR THE RELEASE OF
EMPLOYEE MEDICAL RECORD INFORMATION TO A DESIGNATED REPRESENTATIVE
(NON-MANDATORY)

I, _______, (full name of worker/patient) hereby authorize __________ (individual or
organization holding the medical records) to release to _________ (individual or organization
authorized to receive the medical information), the following medical information from my
personal medical records:

(Describe generally the information desired to be released).

I give my permission for this medical information to be used for the following purpose:

but I do not give permission for any other use or re-disclosure of this information.

(Note: Several extra lines are provided below so that you can place additional restrictions on this
authorization letter if you want to. You may, however, leave these lines blank. On the other
hand, you may want to (1) specify a particular expiration date for this letter (if less than one
year); (2) describe medical information to be created in the future that you intend to be covered
by this authorization letter; or (3) describe portions of the medical information in your records
which you do not intend to be released as a result of this letter.)

Full name of Employee or Legal Representative

Signature of Employee or Legal Representative

Date of Signature

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