Hipaa-Compliant Authorization Form For Release Of Medical Information printable pdf download

HIPAA-COMPLIANT AUTHORIZATION FOR RELEASE OF MEDICAL INFORMATION

I hereby authorize the use and/or disclosure of my individually identifiable health information as

described below. I understand that this authorization is voluntary. I understand that the released

information may be subject to redisclosure by the recipients and no longer be protected by federal

privacy regulations.

Name

Date of Birth

Claim #

SSN

Date of Injury t

is authorized to receive

and use/redisclose the information in connection with my claim for workers’ compensation

benefits. I further authorize that a photocopy of this medical release may be used by the

insurance carrier to order and obtain medical information.

Specific description of information: complete medical record for all dates of service and all

admissions including, but not limited to: history and physical exam; progress notes; office notes

and letters; office chart; laboratory reports; diagnostic test reports including, but not limited to, x-

ray, MRI, CT scan, bone scan, thermography reports; x-ray, MRI, CT scan, bone scan,

thermography films; inpatient admissions and discharge reports; outpatient and emergency room

admissions; complete hospital chart; healthcare records in your file from other providers;

prescription records; operative reports; physical therapy.

The purpose of use or disclosure of patient information is for my workers’ compensation claim.

Patient information may be used or disclosed to administer, determine and/or litigate my claim.

Patient information may be redisclosed to the parties, their agents and representatives; to the

Division of Workers’ Compensation; authorized Independent Medical Examiners including the

Division of Labor Medical Examiners; Division of Administrative Hearings; vocational experts;

entities involved in a third party action arising out of the Workers’ Compensation matter, County

and/or District Courts; and any of my past or present health care providers.

I understand that this authorization will expire upon the closure of my workers’ compensation

claim. I understand that I may revoke this authorization at any time by notifying the providing

organization in writing, but if I do, revocation will not affect any actions the provider took before it

received the revocation. Also, I understand that any use or disclosure made prior to the

revocation of this authorization will not be affected by a revocation.

I understand that I may refuse to sign this form and that my health care and the payment for my

health care will not be affected if I do not sign this form.

I understand that I am entitled to receive a copy of this authorization.

Signature of patient

Or patient’s representative______________________________ Date ________________

Address: __________________________________________________________________

If a patient’s representative signs this authorization, please complete the following:

Printed name of patient’s representative __________________________________________

Relationship to the patient _____________________________________________________

Describe the representative’s authority to act for the patient: __________________________

__________________________________________________________________________

Hipaa-Compliant Authorization Form For Release Of Medical Information