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RELEASE OF MEDICAL INFORMATION

Re:

____________________________v. _________________________________

Alaska Worker's Compensation Claim No. _________________________

TO: Any doctor, chiropractor, hospital, clinic, health insurer, physical therapist, government agency, insurer,

employer or other person, entity, firm, or organization having custody of medical records or medical information

pertaining to me, the undersigned person

I, the undersigned person, give my consent and authorize you to release the following medical records and

information in your possession to ___________________________________________________________, the

defendants, or representative of the defendants, in the above Workers' Compensation Claim filed by me. I also

consent and authorize, but do not necessarily request, you to discuss the following medical records and information

pertaining to me with the defendant or the defendant's representative.

Medical records and information relating to the treatment of my

injury or illness at work,

and the following parts of my body, diagnoses or conditions, organ systems, chief complaints and/or symptoms:

____________________________________________________________________________________________

____________________________________________________________

This authorization releases medical information from _______________________ (two years before the date of my

earliest work injury or illness related to my claim) to the present.

You should interpret the terms "medical information" and "medical records" broadly to include records, reports,

notes, chart notes, letters, photographs, test reports or results (including, as applicable, physical test results,

pathology test results, laboratory test results, x-rays, MRI & CAT scans, EMGs, EKGs, sonograms, etc), bills, and

referral letters in your possession, whether generated by you or received from a third party.

This release of information is intended to include records maintained in my maiden or other names as follows:

_________________________________________

Please consider a photostatic copy of this authorization to release records to be as effective and valid as the original

signed by me.

This release, and all authority to disclose information pertaining to me, shall expire on __________________ (one

year from the date of the signature below), unless earlier revoked by me in writing.

Signature_______________________________________ Dated this ____ day of ___________________, 2000

MY PRINTED NAME: ______________________________________

Under AS 23.30.107, an employee must provide written release of medical and rehabilitation information

relating to the injury. Parties should informally resolve disputes over what is relevant. Only if informal

resolution is impossible, an employee may petition for a prehearing and a protective order within 14 days

after receipt of the request to sign the release. AS 23.30.108.

revised 09/2000

Release Of Medical Information