Authorization To Release Information printable pdf download

AUTHORIZATION TO RELEASE INFORMATION

REGARDING CLAIMANTS SEEKING WORKERS' COMPENSATION BENEFITS

Name of Patient:

Date of Birth:

SECTION I. AUTHORIZATION FOR RELEASE OF INFORMATION AND FOR REDISCLOSURE

I authorize

to disclose and deliver to:

the following information related to me: Any and all information EXCEPT substance abuse (drug or alcohol), mental

health, and AIDS-related information, unless specifically authorized to be released in section II of this form.

NOTE: If the information includes mental health treatment, substance abuse treatment or HIV-related information it will

not be released unless the undersigned patient agrees to the release on the reverse side of this form.

I understand the information is being disclosed and may be used only for legal and/or litigation purposes relating to

claims and/or suit against

I understand that this Authorization may be used to obtain information from health care providers, schools, former and

current employers, providers of vocational rehabilitation services, the Social Security Administration, and the Iowa

Department of Workforce Development. I understand that I have a right to inspect the disclosed information at any

time. This authorization is effective until the conclusion of a contested case on the claim. I understand that I may

revoke this Authorization, except to the extent that action has already been taken in reliance upon it, by giving written

notice to the health care provider or record keeper. I also understand that if I revoke, the revocation will take effect on

the day it is received in writing by the entity from whom disclosure is sought.

I understand that if the person or entity that receives the information requested is not covered by the federal privacy

regulations or is not an individual or entity who has signed an agreement with such a person or entity, the information

described above may be redisclosed and will no longer be protected by the regulations.

Iowa and Federal law provide that I have a right to prohibit redisclosure of confidential medical information and further

disclosure may not be had without my express written authorization, except as indicated below. I understand that the

Recipient of this Authorization, WITHOUT FURTHER AUTHORIZATION, may redisclose this information to:

Parties and their legal counsel, insurers, experts, potential experts, but only after they have been advised of their

obligations under the law and this authorization, including the prohibition against redisclosure of this

information; Agents, employees or representatives of the parties, but only after they are involved in

conducting the prosecution or defense of the case, and only after they have been advised of their

obligations under the law and this authorization, including the prohibition against redisclosure of this

information; Administrative agency and court officials hearing the claim, and their support staff.

I SPECIFICALLY AUTHORIZE AND CONSENT TO ANY SAID DISCLOSURE AND REDISCLOSURE DESCRIBED

ABOVE.

Claimant or Legal Representative

Date

Printed Name and Relationship of Claimant's Legal Representative

Authorization To Release Information