Free HIPAA Medical Release Information Form - Alaska

File Size: 6.1 kB
Pages: 1
File Format: PDF
State: Alaska
Category: Workers Compensation
Word Count: 391 Words, 3,043 Characters
Page Size: Letter (8 1/2" x 11")

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RELEASE OF MEDICAL INFORMATION Re: ____________________________v. _________________________________ Alaska Worker's Compensation Claim No. _________________________

TO: Any doctor, chiropractor, hospital, clinic, health insurer, physical therapist, government agency, insurer, employer or other person, entity, firm, or organization having custody of medical records or medical information pertaining to me, the undersigned person I, the undersigned person, give my consent and authorize you to release the following medical records and information in your possession to ___________________________________________________________, the defendants, or representative of the defendants, in the above Workers' Compensation Claim filed by me. I also consent and authorize, but do not necessarily request, you to discuss the following medical records and information pertaining to me with the defendant or the defendant's representative. Medical records and information relating to the treatment of my injury or illness at work, and the following parts of my body, diagnoses or conditions, organ systems, chief complaints and/or symptoms: ____________________________________________________________________________________________ ____________________________________________________________ This authorization releases medical information from _______________________ (two years before the date of my earliest work injury or illness related to my claim) to the present. You should interpret the terms "medical information" and "medical records" broadly to include records, reports, notes, chart notes, letters, photographs, test reports or results (including, as applicable, physical test results, pathology test results, laboratory test results, x-rays, MRI & CAT scans, EMGs, EKGs, sonograms, etc), bills, and referral letters in your possession, whether generated by you or received from a third party. This release of information is intended to include records maintained in my maiden or other n ames as follows: _________________________________________ Please consider a photostatic copy of this authorization to release records to be as effective and valid as the original signed by me. This release, and all authority to disclose information pertaining to me, shall expire on __________________ (one year from the date of the signature below), unless earlier revoked by me in writing. Signature_______________________________________ Dated this ____ day of ___________________, 2000 MY PRINTED NAME: ______________________________________
Under AS 23.30.107, an employee must provide written release of medical and rehabilitation information relating to the injury. Parties should informally resolve disputes over what is relevant. Only if informal resolution is impossible, an employee may petition for a prehearing and a protective order within 14 days after receipt of the request to sign the release. AS 23.30.108. TO HEALTH CARE PROVIDERS: 45 C.F.R. 164.512(l) exempts workers' compensation disclosures from HIPAA.
revised 06/2003