Fill and Sign the Case Resoulution Form for Civil Rights Jd Supra

State of Maine Workers’ Compensation Board Limited Release of Medical/Health Care Information The State of Maine provides equal opportunity in employment and programs. Auxiliary aids and services are available to individuals with disabilities upon request. For assistance with this form, contact the ADA Coordinator at the Maine Workers’ Compensation Board. Telephone: (888) 801 -9087 or TTY Maine Relay 711. WCB -220 (eff. 9/1/18 ) Name: Date Birth: SSN (last 4 digits): XXX -XX - Date of Injury/Illness : Notice to employer/insurer /employee representative: You may only use forms adopted by the State of Maine Workers' Compensation Board for the release of protected medical/health care information to an employer or its insurer. The Board’s forms may NOT be altered. Abuses may result in penalties. Notice to employee: The employer/insurer contends your health care provider’s medical records , regardless of the date of injury , meaning all records relating to the diagnosis, treatment a nd care, including X-rays, related to the following body part (s ) and/or condition (s ): _______________________________________________________________________________ __________ are needed to determine whether your claim for benefits pursuant to the Worke rs’ Compensation Act (Title 39-A) is compensable. This release authorizes any and all health care providers to release the records , regardless of the date of injury, they have related to the diagnosis, treatment and care, including X -rays, of the body part(s) and/or condition(s) listed above. This release authorizes the release of records dating from ________ until thirty (30) months after the date I sign this form . This release authorizes my health care pr ovider (s) to release records pursuant to a later request after this release is signed through the termination date of this release. You have 14 days from receipt of this certificate to complete and return it to the employer/insurer. If you do not understan d this form, talk with your legal representative. If you do not have a legal representative, a Workers' Compensation Board Claims R esolution Specialist can help you. Voluntary : I understand I may choose not to complete this form . If I choo se not to complete this form, m y claim for benefits may be denied. Limited : I understand this form gives my health care providers permission to release only those health records related to the body part(s ) and/or condition (s ) listed above. This form does NOT authorize oral communication with or by any health care provider with anyone other than me or my representative. Redisclosure: I understand the information provided pursuant to this release can be redi sclosed for the limited purpose of determining whether my claim for benefits pursuant to the Workers’ C ompensation Act (Title 39-A) is compensable. Revocable: I underst and I may revoke this authorization at any time in writing, but doing so may result in a loss of, or reduction in, entitlement to workers’ compensation benefits . I must revoke my authorization by completing and sending WCB Form 220-R to the recipient listed below . Note: You may not cancel this release with respect to medical records already provided. This authorization does NOT authorize the release of information regarding testing, treatment or counseling related to: Psychological matters; substance abuse; HIV/Aids and sexually transmitted diseases. I authorize release of my medical records to : _______________________ ______________________________ ________________ (Name of Recipient) Address of Recipient: ___________________________________________________________________________________________________________ Format Requested ( circle one ): Electronically (if available) : _____________________________ Fax to : __________________ Mail to : __________________________________________________________________ I hereby authorize the above named recipient to obtain from my health care provider (s) subject to the terms of this relea se. Employee or Authorized Representative Signature Date:___________ For purposes of this release, “authorized representative” has the same definition as set forth in 22 M.R.S.A. § 1711 -C(1)(A).