Hipaa-Compliant Authorization For The Release Of Medical Information Pursuant To 45 Cfr 164.508 printable pdf download

HIPAA-COMPLIANT AUTHORIZATION

FOR THE RELEASE OF MEDICAL INFORMATION

PURSUANT TO 45 CFR 164.508

Claimant’s Full Name: __________________________________ Date of Birth: ________________

Social Security Number (last 4 digits only): xxx-xx-____________ Employer’s Name: Occidental Petroleum Corporation

I authorize and request all doctors, hospitals, other health care providers, government agencies, insurers, employers,

schools, training facilities, health plans, policyholders, vendors, welfare plan administrators (“Records Holders”) to give

out my medical records and protected healthcare information as explained on this form. This Information includes, but is

not limited to, any records or facts about my medical condition, treatment, supplies, expenses, coverage or benefits, or

my employment, vocation, education, training, income, current disability or ability to work, whether obtained prior to or

after the date of this Authorization (“Information”).

This Authorization may include disclosure of Information relating to treatment for ALCOHOL and DRUG ABUSE,

GENETIC INFORMATION, MENTAL HEALTH CARE, except psychotherapy notes, and CONFIDENTIAL HIV

RELATED INFORMATION only if I place my initials on the appropriate lines below. In the event the Information includes

any of these types of information, and I initial the line below, I specifically authorize release of such Information to the

Benefit Managers. Include in my Information (Indicate by Initialing):

________ Alcohol/Drug Abuse Treatment

________ Mental Health Information

________ Sexually Transmitted Diseases (STDs)

________ AIDS/ HIV-Related Information

________ Genetic Information

The Genetic Information Nondiscrimination Act of 2008 (GINA) prohibits employers and other entities covered by GINA

Title II from requesting or requiring genetic information of employees or their family members. In order to comply with this

law, we are asking that you not provide any genetic information when responding to this request for medical information.

‘Genetic information,’ as defined by GINA, includes an individual’s family medical history, the results of an individual’s or

family member’s genetic tests, the fact that an individual or an individual’s family member sought or received genetic

services, and genetic information of a fetus carried by an individual or an individual’s family member or an embryo

lawfully held by an individual or family member receiving assistive reproductive services.

Information may be provided to the following individuals or entities ("Benefit Managers"): Occidental Petroleum

Corporation and its subsidiaries (Oxy) and individuals or entities involved in administering, evaluating and managing

welfare benefits plans or my claim and their attorneys; Oxy’s welfare benefit plans; The Prudential Insurance Company of

America, Oxy’s Long-Term Disability administrator; other third party administrators; social security claims adjustors;

Gallagher Bassett Services Inc., Oxy’s Workers’ Compensation administrator; and each of their related companies,

contractors, attorneys, health care providers and occupational health nurses.

The Information will be treated as

confidential. I understand the Information released may be re-disclosed to other parties where state and federal privacy

laws may not protect it.

The purpose of providing this Information to the Benefit Managers is to allow them to evaluate, manage and/or

administer my claim for disability benefits, salary continuation, job accommodation, leave under the federal Family and

Medical Leave Act, local and state leave laws, ADA, workers’ compensation and/or any other welfare benefit program or

leave benefit offered by and through my employer (“Benefits Program”); or to support, defend, or review any

determinations made with respect to my job-related claims, or with respect to the Benefits Program, including eligibility

for the Benefits Program; or to give my Information to any other person or entity, if needed, to determine eligibility for

benefits, to manage my claim under a Benefits Program, or to run a Benefits Program (collectively the “Purpose(s)”).

Any facsimile or copy of this Authorization shall authorize the release of my Information for the listed Purposes. This

Authorization shall be in force and effect for two (2) years from date of execution, at which time this Authorization

expires. If I change my mind before then, I can tell Oxy in writing that I do not want Record Holders or Benefit Managers

to obtain or share any more Information, although that will not change any actions they took before receiving my letter.

Hipaa-Compliant Authorization For The Release Of Medical Information Pursuant To 45 Cfr 164.508

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