Free MD WCC Medical Information Release Authorization A25 - Maryland


File Size: 30.7 kB
Pages: 1
Date: June 10, 2005
File Format: PDF
State: Maryland
Category: Workers Compensation
Author: Webmaster
Word Count: 284 Words, 1,929 Characters
Page Size: Letter (8 1/2" x 11")
URL

http://www.wcc.state.md.us/PDF/PDF_Forms/A25.pdf

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WORKERS' COMPENSATION COMMISSION AUTHORIZATION FOR RELEASE OF MEDICAL INFORMATION
PURSUANT TO COMAR 14.09.01.10 REQUIRING THE DISCLOSURE OF MEDICAL INFORMATION IN A WORKERS' COMPENSATION CLAIM

TO: (Name of Record Holder)
PATIENT/CLAIMANT NAME: | SS#: | | | | DATE OF BIRTH: | | | | DATE OF ACCIDENT: | | |

I, hereby, authorize you to give to:

(Name of Record Requestor) a copy of all information developed by you in my medical record regarding the condition of the following part or parts of my body or my medical condition: (Specify part or parts of body or medical condition.)

while under your observation or treatment or otherwise in your possession. This includes, but is not limited to, history, findings, office and patient charts and files, examination and progress notes, physical evidence prepared by you and any subsequent or future developments relating to my health or mental condition. This authorization is valid for up to one year from the date it is signed. I understand that I may revoke this authorization in writing at any time. Disclosure of medical information pursuant to this authorization is NOT prohibited under the Health Insurance Portability and Accessibility Act ("HIPAA"). The Health Insurance Portability and Accessibility Act ("HIPAA") at 45 CFR sect. 164.512 provides: "a covered entity may disclose protected health information as authorized by and to the extent necessary to comply with laws relating to workers' compensation or other similar programs, established by law, that provide benefits for work-related injuries or illnesses without regard to fault."

________________________________________________ SIGNATURE of claimant/patient or authorized representative _____________________ DATE
10 East Baltimore Street Baltimore, Maryland 21202-1641 410-864-5100 Email: [email protected] Web: http://www.wcc.state.md.us

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WCC Form A-25 (6/10/05)

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