Belte r r a Cor p or at ion S afety M an ual D oc I D C H S M BE L 2 0 1 7 Pa g e 4 79 of 53 8 M ED I C A L R EL E A SE F OR M Doc u m e n t Identif icat ion F R M 023 P age Nu m b e r 1 of 1 Doc u m e n t C r e ation Dat e J a nua r y 1 2013 Im p le m e n tat ion Dat e J a nua r y 1 2013 C onse nt t o re lea se Me di c a l I n for mation Da te He a lt hc a re P rovide r This l e tt e r a uthoriz e s a n y ph y sicia n a ndor othe r m e dica l pra c ti ti one r to r e le a se medic a l i nfo rma ti onre c ords re late d to t he in jur y fo r the purp ose of e na bli n g my e mpl o y e r to de ve lop a re ha bil it a ti on plan The i nf orma ti on is t o be re lea se d to B e lt e r ra C orpor a t e He a lt h S a fe t y I njur y Ma na ge me nt C oordina tor or it s a lt e r na te Core y P icke rin g on the C ompan y s b e ha lf I und e rsta n d that I c a n r e sc ind t his re lea se of in for mation at a n y ti me b y w ritten noti c e to m y e mpl o y e r a nd he a lt h c a r e prov ide r e x c e pt whe re a c ti on ha s tak e n plac e in re li a n c e upon t his authoriz a ti on Da ted this da y of in Empl o y e e s N a me Print Empl o y e e s Si g na tu re