Fillable Form 308-Authorization To Release Medical Records printable pdf download

Form 308 3/12/15

STATE OF UTAH

LABOR COMMISSION

Division of Adjudication

AUTHORIZATION TO DISCLOSE, RELEASE AND USE

PROTECTED HEALTH INFORMATION

(HIPPA COMPLIANT)

Requesting Party: _____________________________________________________ Telephone: (___) ___________________

Address: ______________________________________________________________________________________________

TO: _______________________________________________________________ (Medical Providers as listed on Form 307)

___________________________________________________________________________________________________

This authorization permits you to release a copy of records in your possession regarding any medical treatment and/or

hospitalization of:

Name of Patient _______________________________________________________________________________________

Social Security Number ____________________________________________ Date of Birth _________________________

Date(s) of Injury/Occupational Disease _____________________________________________________________________

I AUTHORIZE you to disclose any information and records regarding the above named individual in your possession. This

includes but is not limited to, your medical findings, diagnosis, treatment, treatment summaries, psychological or psychiatric

evaluations, prognosis, clinic notes, diagnostic reports or radiology films, physical therapy records, pharmacy records, or any

other health information in your records for the past 10 years (15 years if claim is being adjudicated). I understand that

based on the information released it may include information related to any substance abuse.

I UNDERSTAND that the information furnished may be used to evaluate and verify my claim for benefits for a work related

injury or occupational disease. The information obtained is relevant to a workers’ compensation claim(s) and may be used by

persons or organizations performing a service related to, or adjudicating the claim(s).

THIS AUTHORIZATION will expire 365 days following the date signed, but may be revoked by signator in writing to the

requesting party. Revocation of this authorization will not be valid if the requesting party has taken action in reliance upon

such authorization. Please note that the information disclosed or used pursuant to this authorization may be subject to re‐

disclosure and would, therefore, no longer be protected under the terms of the HIPAA privacy rule. I also understand that the

above‐identified health care provider, except under limited circumstances, may not condition treatment, payment,

enrollment in a health plan, or eligibility for benefits on whether this authorization is signed.

A PHOTOCOPY OR SCANNED COPY of this authorization shall be deemed to have the same authority as the original.

I hereby certify that I have read the provisions in this authorization. I understand and agree to its terms, and authorize

disclosure of the information described above.

________________________________________________________

______________________________

Patient

Date

STATE OF UTAH )

: ss

COUNTY OF __________)

On the _____ day of ______________, 20_____, personally appeared before me _________________________________,

the signer of the within instrument, who duly acknowledged to me that he/she executed the same.

___________________________________

NOTARY PUBLIC

Form 308-Authorization To Release Medical Records