HIPAA Statement/Notice of Privacy

PURPOSE

The purpose of this form is to obtain information about your personal health and work exposures. This information will be gathered by your company and sent to an Occupational Health Professional (OHP) to make an accurate assessment of your ability to safely wear a respirator. The OHP will evaluate the information on this form and provide a report to your company. Your company has contracted with Occucare to provide these services.

PRIVACY STATEMENT

The following information requested on the form is private: date of birth, sex, home address and all items under Medical History. The OHC at Occucare will not release any private information about you without your written consent, except as required by law. The OHC at Occucare will notify your company of the following: whether you are medically cleared to wear a respirator, type of respirator you are medically cleared to wear, and if any medical follow up is necessary.