Workers' Compensation Authorization Form To Release Information printable pdf download

Workers' Compensation Authorization Form To Release Information

Workers’ Compensation Authorization Form to Release Information

Patient Information:

Name:_____________________________

Patient ID Number:__________________

Address:___________________________

Date of Injury:______________________

__________________________________

Employer:__________________________

___________________________________ Insurer/Carrier:_____________________

Date of Birth:_______________________

IC File Number:____________________

Pursuant to N.C. Gen. Stat. 97-25.6:

I hereby voluntarily authorize Southeastern Orthopaedic Specialists, P.A. to communicate

relevant medical information relating to my workers’ compensation claim, including

records of evaluation, treatment reports, prognosis, job restrictions or limitations, through

oral, written, or electronic means, to my employer or its insurer/carrier, other health care

providers, rehabilitation professionals/case managers, the North Carolina Industrial

Commission, and other necessary parties, for purpose of: treatment; payment; bill

processing; claims administration, scheduling medical procedures, tests and studies;

referrals; ability to return to work; job restrictions; and all other activities necessary to

process my workers’ compensation claim.

Furthermore, I understand that this form is revocable; however, actions already taken by

Southeastern Orthopaedic Specialists, P.A. in reliance on this authorization cannot be

reversed and revocation of this authorization will not affect those previous actions but

will apply only from the time such written notice of revocation is received by

Southeastern Oethopaedic Specialists, P.A.

______________________________________

__________________________

Signature of Patient or Personal Representative

Date

Workers' Compensation Authorization Form To Release Information