Form Dfs-F2-Dwc-1 - First Report Of Injury Or Illness Template Page 6
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9AUTHORIZATION FOR MEDICAL RECORDS AND COMMUNICATION RELEASE
Name:
Date of Birth:
Social Security #:
I hereby authorize any licensed physician, chiropractor, medical practitioner, hospital, clinic or other medical
or medically related facility, insurance company or other organization, institution or person, that has any
records or knowledge of my mental or physical health, history, condition or wellbeing, to supply such
information to my employer or its insurance carrier, claims administrator or attorneys.
I specifically authorize any treating physician or medical care provider to communicate orally or in writing
with my employer or its insurance company, claims administrator, rehabilitation or medical management
consultant or attorneys as to my care and treatment, and as to any other issues including diagnosis,
prognosis, causal connection of care and treatment to my work injury or duties, and ability to work. I hereby
waive my physician‐patient privilege. In conjunction with this, I also authorize any treating physician or
medical provider to review any additional materials provided to them.
A photocopy of this authorization shall be as valid as the original. This release shall remain valid for the
length of my claim.
Note: Workers’ Compensation Requests Are Exempt From HIPAA. Pursuant to 45 CFR, Sect. 164.512(1)
a covered entity may without penalty under HIPAA disclose protected health information to the extent
necessary to comply with the law relating to workers’ compensation.
NAME‐PLEASE PRINT
SIGNATURE
DATE
Cannon Cochran Management Services, Inc.
2600 Lake Lucien Drive
Suite 225
Maitland, FL 32751
866‐291‐0194
407‐660‐5600
Fax: 217‐477‐6946
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