It has come to the attention of the executive board that the company is using a form, X-4559 (Physician Statement/Release), to gather information about your recent illness/medical procedure with your help. The form itself is not the question, but rather two portions of the form have come into question.
Most times, the form has been given to our member by their supervisor. The top portion is to be filled out by management and they ask that you simply “sign and date” the form and return it to either them or the station nurse.
The issue brought to our attention is two portions of the form. Please see the attached form and notice the highlighted portions. Asking for “Diagnostic Code” and “to release medical records regarding this absence to Medical Services” is information we believe to be privileged between you and your healthcare provider and not required to be provided by you.
We brought the issues of the form to the attention of management late last week, where at that time, involved two of our members in separate matters, requesting those members to sign and return the form. At the conclusion of that meeting, the company “agreed” to accept the form of the above two mentioned matters, with those portions of the form scratched out (Line drawn through) until station management has time to discuss legality with corporate.
In the meantime, if you receive one of these forms from supervision and question any information requested that you provide, please reach out to a member of the executive board for the latest information in regard to this form.
Thanks, Stewart Whitehair, President, UWUA Local 304, Mobile: 304-203-8301, firstname.lastname@example.org