Fill and Sign the Human Resource Handbook Guide to Effective Employee Form

EXPIRATION and CONDITIONS NEW MEXICO WORKERS’ COMPENSATION ADMINIS TRATION WORKER’S AUTHORIZATION FOR USE AND DISCLOSURE OF HEALTH RECORDS Worker/Patient FULL NAME: ______________________________ _____ _____ DOB : ______________ ____ SSN: XXX- XX-_____ __ FOR WCA REFERENCE ONLY: Date/s of Injury: ____________ ______________ WCA Case File Number: _______________ INSTRUCTIONS FOR USE : In accordance with Section 52-10-1 NMSA 1978 , a workers’ compensation health care pro vider shall not require a signed medical authorization, in any form, for records that are directly related to any work place injuries or disabilities claimed by an injured worker. Costs for copying records are subject to non-clinical service s fees set by the Administration , and shall not exceed $1.00 per page for the first ten (10) pages or up to twenty -cent s ($0.20) for each page thereafter. A copy of this authorization may be used as an original. Este formulario es obligatorio al presentar una queja. Si necesitas ayuda para completar este formulario, póngase en contacto con un ombudsman (866) 967 -5667 . RELEASE OF HEALTH CARE RECORDS I, ( Worker’s Name) _____________________________ ___, hereby authorize the following health care provider (HCP) or named facility to release my health care records for the PURPOSE OF facilitating and evaluating my Worker’s Compensation Claim that arises from alleged workplace injur ies or illnesses that occurred on the above date/s of injury. Provider or Facility: Address: Telephone No.: I authorize the following records released (check box, as appropriate): ___ ALL RECORDS ___ SPECIFIC DATES provide a date range for records authorized to be released _________________________________________________ _______________________ RELEASE OF SPECIFIC HEALTH RECORDS I FURTHER AUTHORIZE THE RELEASE OF RECORDS THAT MAY CONTAIN INFORMATION ABOUT THE FOLLOWING: (check any that may apply). ___ Treatment for alcohol and/or substance abuse _ __ Behavioral o r Mental Health, including Psychiatric or Psychological ___ Sexually transmitted diseases ___ HIV o r AIDS ___ Records o f the Department of Health Me dical Cannabis Pr ogram _________ ________________________________________ _____________________ Signature of Worker/Patient/Personal Representative Date PER SON/ENTITY AUTHORIZED TO RECEIVE RECORDS I a uthorize r ecords be released t o my employer, m y employer’s insurer, my a ttorney o r representative, m y employer/insurer’s attorney o r representative, and I ME providers. (To be completed by authorized recipient/s): R ecords to be ___ Picked Up ___ Mail ed ___ Emailed ___ Faxed ___ Other (specify): _ __ ____________________________________________________ _____ _____ ____________________________________________ _______ ___ _ Authorized Recipient/s : Address: Telephone No.: Fax/Email: I UND ERSTAND THAT THIS AUTHORIZATION IS VOLUNTARY AND THAT I MAY REFUSE TO SIGN IT AND SUCH A REFUSAL TO SIGN MAY NOT AFFECT MY TREATMENT OR SERVICES, EXCEPT AS PERMITTED BY LAW. THIS AUTHORIZATION IS LIMITED TO USE AND DISCLOSURE OF MEDICAL RECORDS AND DOES NOT WAIVE ANY PATIENT DOCTOR PRIVILEGE WITHOUT MY SEPARATE AUTHORIZATION AND CONSENT. THIS AUTHORIZATION IS TO BE VALID FOR TWO (2) YEARS FROM THE DATE OF MY SIGNATURE. I UNDERSTAND THAT INFORMATION DISCLOSED PURSUANT TO THIS AUTHORIZATION MAY BE REDISCLOSED BY THE RECIPIENT/ S. I MAY REVOKE THIS AUTHORIZATION AT ANY TIME BY NOTI FIYING THE HEALTH CARE PROVIDER OR FACILITY IN WRITING ; A COPY OF ANY REVOCATION SH OULD BE P ROVIDED TO THE RECIPIENT/S. UPON MY REQUEST, I AM ENTITLED TO A COPY OF THE SIGNED AUTHORIZATION. _________ __________________________________ ______________ ______________________________________________ Signature of Worker/Patient Date _________ ________________________________________________ ______________________________________________ Signature of Personal Representative (if any) Date _________ ________________________________________________ Printed Name of Personal Representative _______________________________________________ Relationship to Worker/Patient Re v. 10/17 11.4.4.9 NMAC