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FAX COVER SHEET
Medical Record Transfer to the
Student Health Care Center
TO:
Student Health Care Center OCCMED
DATE: _____________________
University of Florida
Attn: Preplacement Health Assessment
Coordinator
PH: (352) 294-5700
FAX: (352) 846-2003
FROM:
__________________________
__________________________
Typed Name of Physician
City, State Zip
__________________________
__________________________
Address
Phone #
__________________________
__________________________
Address
State License #
SUBJECT:
Preplacement Health Assessment for:
__________________________
____________________________
Position Number / INOP
Please find the enclosed record of the preplacement health assessment done at the request of
____________________ (supervisor) from the _____________________ (department/research center).
This assessment was done on ___________________ (date, which must be within 60 days of this transfer
date). The record includes the physical exam and medical history information as well as all relative forms.
___________________________ ____________________ ____________________________
HR Representative’s Name HR Rep Phone # HR Representative’s Email Address
RELEASE STATEMENT FOR
TRANSFER OF MEDICAL RECORDS
I authorize the release of my health assessment medical records to the University of Florida’s Student Health
Care Center.
__________________________
__________________________
________________
Candidate’s Name (Printed)
Candidate’s Signature
Date
Revised 04/17