Employee'S Claim Form - Workers' Compensation Commission, Maryland Page 2
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3MARYLAND WORKERS' COMPENSATION COMMISSION
AUTHORIZATION FOR DISCLOSURE OF HEALTH INFORMATION
Pursuant to Labor and Employment Article, §§ 9-709, 9-710, and 9-711, Annotated Code of Maryland, this
authorization must be signed and filed with the Workers' Compensation Commission of Maryland in
conjunction with any claim for workers' compensation benefits.
A. Person Covered by Authorization
This document authorizes the disclosure of protected health information regarding:
/ /
Name/Claimant
Date of Birth
B. Purpose of Disclosure
This document authorizes the disclosure of protected health information for the purpose of processing, adjudicating and
resolving workers' compensation claims.
C. Entities Authorized to Make Disclosure
This document authorizes any health plan, physician, health care professional, dentist, hospital, clinic, laboratory, pharmacy,
medical facility, or other health care provider that has provided payment, treatment or services to me or on my behalf to disclose
my protected health information consistent with this directive.
D. Entities Authorized to Receive Protected Health Information
This document authorizes the disclosure of my protected health information to the following entities and their agents: my
attorney, my employer, and my employer's workers' compensation insurer.
E. Information to be Disclosed
This document authorizes the entities listed in C to disclose protected health information that is relevant to:
1.
The member of the body that was injured as indicated on the claim application form. (see box 33)
2.
The description of how the accidental injury occurred as indicated on the claim application form. (see box 31)
3.
The description of how the occupational disease occurred as indicated on the claim application form. (see box 32)
The protected health information that may be disclosed includes, but is not limited to: history, findings, office and patient charts,
files, examination and progress notes, and physical evidence.
F. I understand that I may revoke this authorization by giving written notice to all parties to my claim for workers' compensation,
except to the extent that this authorization has already been acted on prior to receipt of my revocation.
I understand that the information disclosed by this authorization may be subject to redisclosure by the recipient to a medical
manager, health care professional or registered rehabilitation practitioner, and others consistent with state and federal law.
By signing this form, I am authorizing the disclosure of my protected health information. This authorization is valid for one year
from the date the claim is filed.
__________________________________
__________________________________________
Patient/Claimant Signature
Date
A photocopy, facsimile or electronic transmission of this signed authorization form is valid.
WCC Web Form C1 Page 2 of 3
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