Free DOL FORM 7 - Vermont

DOL FORM 7

(Rev. 8/05

State of Vermont Department of Labor Workers' Compensation Division PO Box 488 Montpelier, VT 05601-0488 (802) 828-2286 MEDICAL AUTHORIZATION NOTE: The release of medical records relative to a workers' compensation claim filed pursuant to Title 21 of the Vermont Statutes is not governed by the terms and provisions of the Health Insurance Portability and Accountability Act of 1996 (HIPAA), 45 CFR 164.512(1).

TO: (Physician or Hospital This, or a photocopy, will authorize you to release to (Insurance Company, Adjuster, or Employer) All medical records you may have relating to the treatment or diagnosis of my injury which occurred on or about , 20 Including history, findings, x-rays, bills, statements, diagnosis, lab reports and all other medical or hospital records in your possession including, but not limited to, records of treatment rendered by you or your facility as well as any medical records in your possession upon which you relied in any way in your treatment and/or diagnosis of my condition. Name: Social Security Number: Date of Birth:

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