Form 14-0043 - Authorization For Release Of Information (Page 2 of 2) in pdf

III. SPECIFIC AUTHORIZATION FOR RELEASE OF INFORMATION

PROTECTED BY STATE OR FEDERAL LAW

I acknowledge that information to be released may include material that is protected by Federal

and/or State law applicable to substance abuse, mental health, and/or AIDS-related information. I

SPECIFICALLY AUTHORIZE the release of confidential information relating to: [Place “YES” or “NO” in

ALL applicable boxes:]

_____ Substance Abuse (Drug or Alcohol) Information from all health care providers and facilities and

any other person or entity in possession of records concerning me.

_____ Mental Health Information from all health care providers and facilities and any other person or

entity in possession of records concerning me.

_____ HIV or AIDS-related Information, Diagnosis, and test results from all health care providers and

facilities and any other person or entity in possession of records concerning me.

Furthermore, I SPECIFICALLY AUTHORIZE disclosure and redisclosure of this confidential

information to all of the persons referred to in section II above.

In order for the above information to be released, you must sign here AND at the end of this

form.

_____________________________________________

_____________________________________

Signature of Patient or Legal Guardian or Personnel

Date

Representative,

_________________________________________________________

Relationship, if NOT the patient

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.

A photocopy, or exact reproduction of this signed Authorization shall have the same force and

effect as this original.

I hereby authorize the release of information as indicated above.

I HEREBY ACKNOWLEDGE THAT I HAVE RECEIVED A COPY OF THIS DOCUMENT.

________________________________________________

_____________________________________

Signature of Person Whose Records are Being Requested

Date of signing

________________________________________________________________________________________

Street Address

City/State/Zip Code

_________________________________________________________

Relationship, if NOT the Person Whose Records Are Being Requested

___________________________________________________________

Print Name of Person or Person’s Personal Representative

14-0043 (08/03)

This form may be used in connection with claims under the jurisdiction of the Iowa Workers’ Compensation

Commissioner.

Form 14-0043 - Authorization For Release Of Information Page 2

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