Fillable Claimant'S Authorization To Disclose Health Information printable pdf download

CLAIMANT'S AUTHORIZATION TO DISCLOSE HEALTH INFORMATION

(Pursuant to HIPAA)

INSTRUCTIONS

To the Claimant: The Health Insurance Portability and Accountability Act of 1996 (HIPAA) set standards for guaranteeing the privacy of

individually identifiable health information and the confidentiality of patient medical records. By completing and signing this form, you

authorize your health care provider to file medical reports with the parties that you choose (such as the Workers' Compensation Board,

your employer's insurance carrier, your attorney or representative, etc.) by checking the appropriate boxes below.

You have the right to refuse to sign this Authorization. If you sign, you have the right to revoke this Authorization at any time by mailing a

request to revoke to the health care provider. You have the right to receive a copy of this Authorization.

IMPORTANT: Failure to execute this authorization may interfere with your ability to obtain workers' compensation benefits.

CLAIMANT'S NAME

CLAIMANT'S SOCIAL SECURITY NUMBER

CLAIMANT'S DATE OF BIRTH

LIST ALL WCB CASE NUMBER(S) AND CORRESPONDING DATE(S) OF ACCIDENT FOR WHICH YOU ARE GRANTING AUTHORIZATION

I, __________________________________________________________, hereby authorize my treating health provider,

Claimant's Name

_____________________________________________________, to disclose the following described health information:

Health Provider's Name

_________________________________________________________________________________________________

(check all that apply; give names and addresses, if known)

This information can be disclosed to the following parties:

New York State Workers' Compensation Board

My current/former employer _______________________________________________________________________

Workers' compensation insurance carrier(s) __________________________________________________________

Third-party administrator ___________________________________________________________________________

My attorney/licensed representative __________________________________________________________________

The Uninsured Employer's Fund

)

(this fund is responsible for paying the medical bills and lost wage benefits when an employer is uninsured.

Special Funds Conservation Committee

(for cases under Section 25-a or 15-8 of the Workers' Compensation Law)

Section 25-a: If your claim is being reopened after being previously closed, the Special Fund for Reopened Cases may be responsible for

paying your medical bills and lost wage benefits.

Section 15-8: If you had a medical condition that existed prior to this injury, the Special Fund for Second Injuries may be responsible for

reimbursing your employer's insurance carrier after a period of time has elapsed.

Redisclosure: I understand that once the above-referenced health care provider discloses health information based on this

Authorization, that health information is no longer protected by HIPAA and the Privacy Rule.

Expiration Date: This Authorization expires upon the final closing of the workers' compensation claim(s) for which it is

executed.

I have had the opportunity to review and understand the content of this Authorization. By signing this

Authorization, I confirm that it accurately reflects my wishes.

_____________________________________ ______________________________________ ______________________

Printed Name of Claimant or Legal Representative

Signature of Claimant or Legal Representative

Date

If Authorization signed by a legal representative on behalf of claimant, state relationship to claimant_____________________________________________and

basis for authority (e.g. claimant is a minor; patient is deceased and representative is the claimant in a workers' compensation proceeding or represents the

estate) ___________________________________________________________________________________________________________________________

TO THE HEALTH PROVIDER: Keep the original of this Authorization on file. A copy must be given to the patient/claimant upon request.

DO NOT SEND TO THE NEW YORK STATE WORKERS' COMPENSATION BOARD.

HIPAA-1 (12-03)