HIPAA-COMPLIANT AUTHORIZATION FOR RELEASE OF MEDICAL INFORMATION
I hereby authorize the use and/or disclosure of my individually identifiable health information as
described below. I understand that this authorization is voluntary. I understand that the released
information may be subject to redisclosure by the recipients and no longer be protected by federal
Date of Birth
Date of Injury t
is authorized to receive
and use/redisclose the information in connection with my claim for workers’ compensation
benefits. I further authorize that a photocopy of this medical release may be used by the
insurance carrier to order and obtain medical information.
Specific description of information: complete medical record for all dates of service and all
admissions including, but not limited to: history and physical exam; progress notes; office notes
and letters; office chart; laboratory reports; diagnostic test reports including, but not limited to, x-
ray, MRI, CT scan, bone scan, thermography reports; x-ray, MRI, CT scan, bone scan,
thermography films; inpatient admissions and discharge reports; outpatient and emergency room
admissions; complete hospital chart; healthcare records in your file from other providers;
prescription records; operative reports; physical therapy.
The purpose of use or disclosure of patient information is for my workers’ compensation claim.
Patient information may be used or disclosed to administer, determine and/or litigate my claim.
Patient information may be redisclosed to the parties, their agents and representatives; to the
Division of Workers’ Compensation; authorized Independent Medical Examiners including the
Division of Labor Medical Examiners; Division of Administrative Hearings; vocational experts;
entities involved in a third party action arising out of the Workers’ Compensation matter, County
and/or District Courts; and any of my past or present health care providers.
I understand that this authorization will expire upon the closure of my workers’ compensation
claim. I understand that I may revoke this authorization at any time by notifying the providing
organization in writing, but if I do, revocation will not affect any actions the provider took before it
received the revocation. Also, I understand that any use or disclosure made prior to the
revocation of this authorization will not be affected by a revocation.
I understand that I may refuse to sign this form and that my health care and the payment for my
health care will not be affected if I do not sign this form.
I understand that I am entitled to receive a copy of this authorization.
Signature of patient
Or patient’s representative______________________________ Date ________________
If a patient’s representative signs this authorization, please complete the following:
Printed name of patient’s representative __________________________________________
Relationship to the patient _____________________________________________________
Describe the representative’s authority to act for the patient: __________________________