Form 14-0043 - Authorization For Release Of Information printable pdf download

AUTHORIZATION FOR RELEASE OF INFORMATION

REGARDING CLAIMANTS SEEKING WORKERS' COMPENSATION BENEFITS

To any medical practitioner or institution, including but not limited to, ________________________

________________________________________________________________________________

Name of Person Whose Records are Being Requested: ______________________________________

Maiden or Previous Name(s): _____________________________________________________________

Birthdate: _____________________ Social Security No: __________ - __________ - __________

I. AUTHORIZATION FOR RELEASE OF INFORMATION

The undersigned hereby authorizes all health care providers and facilities and any other person or

entity in possession of records concerning me to disclose and deliver to

__________________________________________________________________________________________________

______________________________________________________________________________

(name of individual, firm, or institution and address)

hereinafter referred to as “Recipient,” all information, including all protected health information, from

whatever source relating to the above-named person.

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 ______________________________________________________

and ____________________________________________________________________.

II. REDISCLOSURE

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

federal or state privacy regulations or is not an individual or entity who has signed an agreement with

such a person or entity agreeing to maintain the confidentiality of the information, the information

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

Iowa and/or federal law provides that I have a right to prohibit redisclosure of certain types of

confidential medical information and further disclosure may not be had without my express written

authorization, as indicated below.

I further understand that the Recipient, WITHOUT FURTHER AUTHORIZATION, may redisclose

said information to parties and their legal counsel, insurers, experts, potential experts, anyone against

whom claim is or has been made, administrative agency and court officials hearing the claim, and any

agents, employees, or representatives of any said persons.

I SPECIFICALLY AUTHORIZE AND CONSENT TO THE DISCLOSURE AND REDISCLOSURE

DESCRIBED ABOVE.

Federal and/or State law specifically require that any disclosure or redisclosure of substance

abuse, alcohol or drug, mental health, or AIDS-related information must be accompanied by the following

written statement:

This information has been disclosed to you from records protected by Federal confidentiality

rules (42 CFR Part 2). Federal rules prohibit you from making any further disclosure of this information

unless further disclosure is expressly permitted by the written consent of the person to whom it pertains

or as otherwise permitted by 42 CFR Part 2. A general authorization for the release of medical or other

information is NOT sufficient for this purpose. The Federal rules restrict any use of the information to

criminally investigate or prosecute any alcohol or drug abuse patient.

See also Chapter 228 of the Iowa Code and Chapter 141A of the Iowa Code and other

applicable laws.

Form 14-0043 - Authorization For Release Of Information