(TO BE COMPLETED BY EMPLOYEE)

AUTHORIZATION FOR RELEASE OF MEDICAL INFORMATION IN RESPONSE TO

REQUEST FOR A WORKPLACE ARRANGEMENT

I, , hereby authorize my health care provider to

release my personal health information. This information will be provided to my
employer, Verizon Wireless (the “Company”), for the purpose of evaluating and
understanding my request and/or need for a workplace arrangement. This
authorization extends to any type of medical information deemed necessary by my
provider to respond to the specific questions in Sections A through D below.
I understand that I have the right to revoke this authorization at any time by
giving a written notice to the Company or the provider named above. Such
revocation shall not apply to any information that has been released prior to
revocation of this authorization.
I also understand that authorizing the disclosure of my medical information is
voluntary. I can refuse to sign this authorization. I further understand that I have the
right to inspect and copy the information disclosed as a result of this authorization. I
understand that any disclosure of information carries with it the potential for an
unauthorized re-disclosure, which may or may not be protected by federal or state
confidentiality rules. If I have any questions about the disclosure or use of this
information, I may contact my local Human Resources representative.

Employee’s Signature Date

Human Resources
Revised 4/1/06
(TO BE COMPLETED BY EMPLOYEE’S HEALTH CARE PROVIDER)

Patient/Employee’s Name: _____________________________________________

A. Questions related to the impairment

Does the employee have a mental or physical impairment? Yes No

What is the impairment?

Is the impairment long term or permanent? Yes No

Does the impairment substantially limit a major life activity? Yes No

What major life activity(ies)?

B. Questions related to limitations

What specific job tasks are problematic as a result of the impairment? (Please be as
specific as possible)

C. Questions related to potential workplace arrangement options

Do you have any suggestions regarding possible workplace arrangements that would
assist the employee in performing the job tasks identified in B. above? If so, what are
they? If you are suggesting time off, please specify start and end dates. (Please be as
specific as possible)

Human Resources
Revised 4/1/06
D. Additional Information
Please provide any additional information that will help us assess the employee’s
request for a workplace arrangement.

Signature:

Date:

Please print name and title:

Office address:

Phone:

Fax:

Email:

Human Resources
Revised 4/1/06