Documentation Request - Green Bridge Society

Patient Information

Full Legal Name *

Date of Birth *

Phone (optional)

Email *

Recipient (Who We're Sending To)

Recipient Type *

Recipient Name *

Delivery Method *

Recipient Contact Details *

Purpose of Request

Purpose *

HIPAA Authorization — Information to Release

Select what we are authorized to disclose (minimum necessary).

Confirmation of evaluation date and certification relationship Diagnosis / qualifying condition information (when supported) Symptom impact and functional limitations General safety/impairment counseling (e.g., not working while impaired) Copies of documents I upload for this request

Restrictions / Do NOT disclose (optional)

Authorization Expiration *

Upload Documents

Employer/Agency Form *

Upload the form your employer/agency provided (PDF preferred). Max 8MB.

Supporting Documents (optional)

Medical records, prior documentation, etc.

Electronic Signature & Acknowledgments

Type Your Full Legal Name *

Date *

HIPAA Authorization: I authorize Green Bridge Society to disclose the minimum necessary information I selected above to the recipient listed. I understand I may revoke this in writing at any time, and that disclosed information may be redisclosed by the recipient. Scope & Limitations: I understand Green Bridge provides PA medical cannabis certifications and is not my primary treating provider. Documentation is limited to medically supportable information. Green Bridge cannot provide ADA determinations, fitness-for-duty conclusions, or drug test predictions.