The Workers Compensation Medical Records Release Form is a crucial document in the U.S. workers' compensation system, required when an employee suffers a work-related injury or illness. This form ensures compliance with HIPAA regulations while allowing necessary medical information to be shared with relevant parties for claim processing. It specifies what medical information can be released, to whom, and for what duration. The form must adhere to both federal privacy laws and state-specific workers' compensation regulations, making it essential for proper claim management and medical treatment coordination.
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1. Patient Information: Basic identifying information about the worker/patient including name, address, date of birth, and social security number
2. Healthcare Provider Information: Details of the healthcare provider(s) authorized to release information, including name, address, and contact information
3. Scope of Authorization: Specific description of what medical information can be released, including types of records, date ranges, and any specific conditions
4. Purpose of Disclosure: Statement that release is for workers' compensation claim purposes and specific use of the information
5. Duration of Authorization: Time period for which the authorization is valid and expiration date
6. Rights Statement: Patient's rights regarding the authorization including right to revoke, right to inspect records, and voluntary nature of signing
7. Signature Block: Space for patient signature, date, and witness signature if required
1. Specific Injury Details: Optional section for details about the work-related injury including date of injury, type of injury, and body parts affected
2. Re-disclosure Notice: Optional section containing statement about potential re-disclosure of information to other parties
3. Insurance Carrier Information: Optional section for details of the workers' compensation insurance carrier including claim number and adjuster information
1. List of Healthcare Providers: Schedule listing all healthcare providers involved in the worker's care when multiple providers are involved
2. Specific Records Request Form: Detailed form specifying exact records needed from each provider including dates of service and types of records
3. State-Specific Addendum: Additional requirements and disclosures specific to the state jurisdiction where the form will be used
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