Employee Release of Information

I, _____________________________, give Choice Health Care permission to receive information that pertains to my employment with Choice Health Care.

              ___________________ Health Information (TB, Physical, etc.)

              ___________________ Wage Information

              ___________________ Employment Information

                 * Mark all that applies

_____________________                     __________________________

Employee Signature                                 Date

I, _____________________________, give Choice Health Care permission to give information that pertains to my employment with Choice Health Care.

              ___________________ Health Information (TB, Physical, etc.)

              ___________________ Wage Information

              ___________________ Employment Information

                 * Mark all that applies

_____________________                     __________________________

Employee Signature                                 Date