AUTHORIZATION FOR RELEASE OF MEDICAL INFORMATION

(Workers' Compensation HIPAA-Compliant Medical Records Release)

PART 1: PATIENT/INJURED WORKER INFORMATION

Patient Name: [FULL LEGAL NAME]

Date of Birth: [DATE]

Social Security Number: [XXX-XX-XXXX]

Address:
[STREET ADDRESS]
[CITY], [STATE] [ZIP CODE]

Phone: [PHONE NUMBER]

Email: [EMAIL]

PART 2: CLAIM INFORMATION

Date of Injury: [DATE]

Employer at Time of Injury: [EMPLOYER NAME]

Workers' Compensation Claim Number: [CLAIM NUMBER]

WCAB/Board Case Number (if applicable): [CASE NUMBER]

Body Parts Injured: [LIST BODY PARTS]

Brief Description of Injury:
[DESCRIPTION]

PART 3: AUTHORIZATION TO RELEASE RECORDS

3.1 Authorization Statement

I, [PATIENT NAME], hereby authorize the release of my protected health information as described below, in connection with my workers' compensation claim.

3.2 Information to be Released

I authorize the release of:

☐ ALL medical records relating to the injury described above, including:
- Office visit notes and progress reports
- Hospital records (including emergency room)
- Surgical reports and operative notes
- Laboratory and pathology results
- Radiology and imaging reports and films
- Physical therapy and rehabilitation records
- Prescription and medication records
- Mental health records (if related to claim)
- Billing records and itemized statements

☐ LIMITED records - Only the following:
[SPECIFY RECORDS TO BE RELEASED]
____________________________________________________________________________

Date Range of Records: From [DATE] to [DATE]

☐ All records relating to the claimed injury, regardless of date

3.3 Specific Types of Records (Check all that apply)

☐ Primary care physician records
☐ Specialist records (specify): [SPECIALTY]
☐ Hospital/Emergency room records
☐ Surgical records
☐ Physical therapy records
☐ Chiropractic records
☐ Radiology/imaging records (including films/images)
☐ Laboratory records
☐ Pharmacy/prescription records
☐ Mental health records
☐ Substance abuse treatment records
☐ Workers' compensation medical-legal reports
☐ Prior workers' compensation records
☐ Employment medical records
☐ Other: [SPECIFY]

3.4 Sensitive Information

I specifically authorize the release of the following sensitive information (if applicable):

☐ HIV/AIDS information
☐ Mental health records
☐ Substance abuse/alcohol treatment records
☐ Sexually transmitted disease information
☐ Genetic information

☐ I do NOT authorize release of the above sensitive information

PART 4: PERSONS/ENTITIES AUTHORIZED TO RELEASE RECORDS

I authorize the following healthcare providers and entities to release my records:

Provider 1:

Name: [PROVIDER/FACILITY NAME]
Address: [ADDRESS]
Phone: [PHONE]
Fax: [FAX]

Provider 2:

Name: [PROVIDER/FACILITY NAME]
Address: [ADDRESS]
Phone: [PHONE]
Fax: [FAX]

Provider 3:

Name: [PROVIDER/FACILITY NAME]
Address: [ADDRESS]
Phone: [PHONE]
Fax: [FAX]

☐ All healthcare providers who have treated me for the conditions related to this workers' compensation claim

☐ All healthcare providers who have treated me for the affected body parts, regardless of when treatment occurred

PART 5: PERSONS/ENTITIES AUTHORIZED TO RECEIVE RECORDS

I authorize release of my records to the following:

5.1 Workers' Compensation Parties

☐ My Attorney:
Name: [ATTORNEY NAME]
Firm: [FIRM NAME]
Address: [ADDRESS]
Phone: [PHONE]
Fax: [FAX]
Email: [EMAIL]

☐ Workers' Compensation Insurance Carrier:
Name: [CARRIER NAME]
Claims Examiner: [NAME]
Address: [ADDRESS]
Phone: [PHONE]
Fax: [FAX]

☐ Employer:
Name: [EMPLOYER NAME]
Contact: [NAME]
Address: [ADDRESS]

☐ Defense Attorney:
Name: [ATTORNEY NAME]
Firm: [FIRM NAME]
Address: [ADDRESS]

☐ Qualified Medical Evaluator (QME):
Name: [NAME]
Address: [ADDRESS]

☐ Agreed Medical Evaluator (AME):
Name: [NAME]
Address: [ADDRESS]

5.2 Other Recipients

☐ Copy Service:
Name: [COMPANY NAME]
Address: [ADDRESS]

☐ Other:
Name: [NAME]
Address: [ADDRESS]
Purpose: [PURPOSE]

PART 6: PURPOSE OF DISCLOSURE

This information is being released for the following purposes:

☐ Evaluation and processing of workers' compensation claim
☐ Medical treatment and continuing care
☐ Medical-legal evaluation (QME/AME)
☐ Determination of benefits
☐ Litigation and legal proceedings
☐ Utilization review
☐ Settlement evaluation
☐ Other: [SPECIFY]

PART 7: EXPIRATION

7.1 Duration of Authorization

This authorization shall remain in effect:

☐ Until [SPECIFIC DATE]

☐ For [NUMBER] months/years from the date signed

☐ Until the conclusion of the workers' compensation claim (including all appeals)

☐ Until revoked in writing by the patient

7.2 Revocation

I understand that I may revoke this authorization at any time by providing written notice to the persons/entities authorized to release my information. Revocation will not affect any action taken in reliance on this authorization before the revocation is received.

PART 8: PATIENT RIGHTS AND ACKNOWLEDGMENTS

8.1 Acknowledgments

I understand and acknowledge that:

☐ I have the right to refuse to sign this authorization.

☐ If I refuse to sign, it may affect the processing of my workers' compensation claim, including potential denial or delay of benefits.

☐ I have the right to receive a copy of this authorization upon request.

☐ Information disclosed pursuant to this authorization may be subject to re-disclosure by the recipient and may no longer be protected by HIPAA.

☐ The healthcare provider may not condition treatment on whether I sign this authorization, except for treatment that is solely for the purpose of creating health information for a third party.

☐ I have the right to revoke this authorization at any time in writing, except to the extent that action has already been taken based on this authorization.

☐ This authorization is made voluntarily.

8.2 Workers' Compensation Specific Acknowledgments

☐ I understand that workers' compensation law may require disclosure of medical information related to my claim without my authorization.

☐ I understand that medical records may be used in legal proceedings related to my workers' compensation claim.

☐ I understand that defense attorneys and insurance company representatives may review my medical records.

PART 9: SIGNATURE

By signing below, I authorize the release of my medical information as described above.

Patient Signature: _________________________________

Printed Name: [NAME]

Date: [DATE]

PART 10: REPRESENTATIVE SIGNATURE (IF APPLICABLE)

☐ This authorization is signed by a personal representative because:

☐ Patient is a minor (under 18)
☐ Patient is incapacitated
☐ Patient is deceased
☐ Other legal authority: [EXPLAIN]

Representative Signature: _________________________________

Printed Name: [NAME]

Relationship to Patient: [RELATIONSHIP]

Legal Authority (attach documentation): [DESCRIPTION]

Date: [DATE]

PART 11: WITNESS (IF REQUIRED)

Witness Signature: _________________________________

Printed Name: [NAME]

Date: [DATE]

PART 12: FOR HEALTHCARE PROVIDER USE

Records Request Received

Date Received: [DATE]

Received By: [NAME]

Records Sent:
☐ Yes - Date: [DATE]
☐ No - Reason: [REASON]

Records Sent To: [RECIPIENT]

Method: ☐ Mail ☐ Fax ☐ Electronic ☐ Pick-Up

Charges:
☐ No charge
☐ Charges assessed: $[AMOUNT]
☐ Paid ☐ Billed

Staff Signature: _________________________________

Date: [DATE]

PART 13: INSTRUCTIONS FOR HEALTHCARE PROVIDERS

Responding to This Authorization:

1. Verify Identity: Confirm the patient's identity matches your records.

2. Verify Authorization: Ensure the authorization is signed and dated, and has not expired or been revoked.

3. Scope of Records: Release only the records specified in Part 3.

4. Time Frame: California law requires response within 15 days of receipt. Other states may vary.

5. Charges: You may charge reasonable fees for copying records as permitted by state law.

6. Send Records To: Mail or fax records to the recipient listed in Part 5.

7. Document Disclosure: Maintain a record of this disclosure as required by HIPAA.

Questions:

Contact the requesting party at the phone/fax listed in Part 5.

PART 14: STATE-SPECIFIC REQUIREMENTS

California:

• Health & Safety Code Section 123100 et seq. governs medical records access
• Maximum copy fees are regulated by statute
• 15-day response time required

Texas:

• Occupational Health & Safety Code Chapter 408 governs WC medical records
• Maximum fees regulated by Texas Administrative Code

[YOUR STATE]:

[INSERT STATE-SPECIFIC REQUIREMENTS]

[END OF DOCUMENT]