Fill and Sign the New Mexico Authorization Form

NEW MEXICO WORKERS’ COMPENSATION ADMINISTRATION 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 provider 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 services fees set by the Administration, and shall not exceed $1.00 per page for the frst ten (10) pages or up to twenty-cents ($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 injuries 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 ____ Sexually transmitted diseases ____ HIV or AIDS ____Behavioral or Mental Health, including Psychiatric or Psychological ____Records of the Department of Health Medical Cannabis Program _________________________________________________ _____________________ Signature of Worker/Patient/Personal Representative Date PERSON/ENTITY AUTHORIZED TO RECEIVE RECORDS I authorize records be released to my employer, my employer’s insurer, my attorney or representative, my employer/insurer’s attorney or representative, and IME providers. (To be completed by authorized recipient/s): Records to be ___ Picked Up ___ Mailed ___ Emailed ___ Faxed ___ Other (specify): ____________ _______________________________________________________________________________________________________________________ _ Authorized Recipient/s: Address: Telephone No.: Fax/Email: Rev. 10/17 11.4.4.9 NMAC EXPIRATION and I UNDERSTAND 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 NOTIFIYING THE HEALTH CARE PROVIDER OR FACILITY IN WRITING; A COPY OF ANY REVOCATION SHOULD BE PROVIDED 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 Rev. 10/17 11.4.4.9 NMAC