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NY UCS-575 2008-2024 free printable template

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AUTHORIZATION TO PERMIT INTERVIEW OF TREATING PHYSICIAN BY DEFENSE COUNSEL TO: Physicians name and addressYou are hereby authorized to discuss certain medical condition(s) involving: with Patients
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WITH A PHYSICIAN This medical condition consists of: (Refer to page 704) Duty to report any medical condition Informing the Defense of any medical condition Notifying the Director of Medical Personnel Informing the director of any medical condition Responsibility for investigation and follow-up The Duty to report a medical condition The duty to report a medical condition is applicable to all physicians, hospital administrators, medical assistants and assistants, hospital administrators and supervisors, medical consultants and consultants, and other medical personnel who render medical care to military personnel and whose actions are controlled by Department policy. When a military police officer has reason to suspect or have reasonable cause to believe that a military medical officer has failed to conduct a proper investigation of a medical condition, the investigation is automatically referred to the Medical Inspection Bureau. The investigation may be completed or not completed within 72 hours of being commenced by the military police officer in which event a report may be made on the medical condition to the Medical Inspection Bureau. The report should include a statement concerning the military medical officer's failures to make the medical investigation or reports available to the investigating civilian or other medical personnel. When a military police officer is notified of a medical condition and the medical officer fails to disclose the condition within 5 working days after the notification or report, the military police officer has the right to file an administrative complaint for failure to report within 15 days from the day the complaint is filed. Duty for physician to disclose information It is the duty of a physician who has care or treatment responsibility for a person suffering from a condition to: (1) Provide such information, on request, as is necessary to permit a military police officer to carry out the duties prescribed by applicable law or regulation. (2) Promptly notify the military police officer of any known or suspected violation of the law or regulation. (3) Provide any other information, on request, as the military police officer may require. When a military police officer has reason to suspect that a physician has omitted any information about a medical condition which should have been disclosed to the military police officer or that information which should have been disclosed to the military police officer was not promptly provided on request, the medical officer has the right to file an administrative complaint for violation of duty (1) to make reports, and (2) to timely provide reports.

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