AUTORIZACIÓN DEL TRABAJADOR PARA LA REVELACIÓN DE INFORMACIÓN MÉDICA
PRESERVADA PARA PROPÓSITOS DE LA COMPENSACIÓN A LOS TRABAJADORES
(EN CONFORMIDAD CON HIPAA)
Yo, (imprima el Nombre del Trabajador) _______________________, por este medio autorizo al proveedor de
atención médica (PAM) – (el nombre del PAM es opcional y no se requiere para revelar la información medica)
(Imprima el nombre del Proveedor de Atención Médica)_____________________________________________el
uso o revelación de mi información médica descrita en esta autorización.
1. INFORMACIÓN WCA N ú m. _____________________
Fecha de Nacimiento _________________Fecha de la lesión ________________SSN________________________
Dirección: ________________________________________________________Teléfono: ____________________
Representante del Trabajador (si lo hay) ________________________________Teléfono: ____________________
Dirección: ____________________________________________________________________________________
2. EMISIÓN
Yo autorizo al Proveedor de Atención Médica o a cualquier miembro o empleado de su oficina o asociación que me
haya consultado o atendido, y de igual manera a cualquier hospital o centro de tratamiento en el cual he sido
atendido, para que proporcione y revele copias legibles de cualquier y toda la información concerniente a mi
condición física y siquiátrica, de la atención y tratamiento, a mi empleador, _____________________________, y/o
su compañía de seguros, ___________________________________, y/o sus abogados y a los representantes
debidamente autorizados de la Administración para la Compensación a los Trabajadores y a su actual contratista de
la contención del costo médico o sus debidos agentes autorizados. Copias de todos los documentos emitidos
conforme a esta autorización deberán ser enviados a la agencia que está requiriendo la información y a mí o a mi
representante como se menciona anteriormente.
3. Yo entiendo que la siguiente información será publicada seguida a una reclamación de la compensación a
los trabajadores por una lesión o enfermedad ocupacional relacionada al trabajo: informes médicos, apuntes clínicos,
apuntes de enfermería, el historial de lesiones del paciente, quejas objetivas y subjetivas del paciente, radiografías,
los resultados de análisis y reconocimiento, interpretación de radiografías y otros análisis (incluso una copia del
informe); diagnosis y prognosis, recibos de pago del hospital, recibos de pago para consultas y tratamientos por el
proveedor de atención médica, recibos del pago efectuado, y cualquier información pertinente y esencial que tenga
en su poder el proveedor de atención medica. Esta autorización también incluye, en caso de ser aplicable, lo
siguiente: cualquier diario de operaciones del hospital, diarios de urgencias, informes de los comités de tejidos,
informes y constancias siquiátricas, constancias de terapia física y toda constancia de tratamiento de paciente
externo. Esta autorización se puede usar para pedir la carta oficial al proveedor de atención médica (Form Letter to
Health Care Provider), que ha sido aprobada por la Administración para la Compensación a los Trabajadores.
Entiendo que tengo el derecho a limitar la información que pueda ser proporcionada al firmar esta autorización para
tal efecto provisto por la ley.
CONDICIONES
4. Yo entiendo que el propósito de este requerimiento es para determinar el nivel preciso de
beneficios de compensación a los trabajadores y que puede incluir información con respecto a lo siguiente: para
determinar mi estado de enfermedad ocupacional o lesión; para determinar mi elegibilidad a los beneficios de
compensación a los trabajadores; para determinar mi estado médico presente y futuro después de una lesión
ocupacional; para determinar mi estado médico actual y/o la capacidad para regresar al trabajo.
11.4.4.9.18.2.C NMAC (rev. 1/07)
5. Derecho a revocar: Yo entiendo que tengo el derecho de revocar esta autorización a cualquier
hora notificando a la compañía mencionada en los párrafos 1 y 2. Entiendo que la revocación es únicamente
efectiva después de ser recibida y registrada por esa compañía y que cualquier uso o revelación hecha antes de la
revocación bajo esta autorización no será afectada por la revocación. Sobreentiendo que mi revocación a esta
autorización puede afectar mi habilidad para recibir beneficios por lesiones ocupacionales o de compensación a los
trabajadores regida por esta revocación.
6. Yo entiendo que después de que esta información sea revelada, el receptor puede continuar
usándolo ejerciendo mi autorización anterior, sin importar mis revocaciones subsecuentes a esta autorización.
Sobrentiendo que protecciones diferentes pueden estar disponibles conforme a la ley estatal y federal.
7. Yo entiendo que la información a ser publicada de acuerdo con una lesión o enfermedad
ocupacional/relacionada con el trabajo/reclamo de la compensación a los trabajadores puede también ser revelada a
la Administración para la Compensación a los Trabajadores y a su actual contratista de la contención del costo
médico, o sus agentes debidamente autorizados.
8. Por este medio renuncio cualquier regulación y/o reglas de ética que pueda de otra manera
prevenir a cualquier hospital o proveedor de la salud u otras personas que me han atendido o examinado en una
capacidad profesional de revelar dichos apuntes.
9. Una fotostática u otra copia de este documento, el cual contiene mi firma, deberá ser
considerada tan efectiva y válida como el original, y deberá ser aceptada por aquellos que se les envía o proporciona
por un periodo de seis (6) meses de la fecha en que fue firmada.
10 Este documento no autoriza ninguna conferencia personal o telefónica o correspondencia directa entre
ningún proveedor de la salud y un representante de mi empleador, su abogado o compañía de seguros para discutir
mi caso y es únicamente para la publicación de documentación médica como se explica en el presente documento.
Se permite únicamente una comunicación breve con el propósito limitado de obtener información médica.
11. Yo entiendo que tengo derecho a una copia de esta autorización y a cualquier documento que se haya
proporcionado en esta autorización. Estoy pidiendo una copia de esta autorización __Sí __No – Si es sí, yo he
recibido una copia____(inicial). Entiendo que esta autorización terminará en seis (6) meses de la fecha de que la
firmé, a menos que yo la revoque antes, siguiendo a lo que se dice en el párrafo 5.
Firma del Trabajador _________________________________________________________Fecha______________
Sección del Representante Personal:
Si un representante personal ejecuta esta forma, ese representante dispone que él o ella tenga la autorización para
firmar esta forma en base de (imprima las bases detalladas para la representación).
_____________________________________________________________________________________________
_____________________________________________________________________________________________
Firma del Representante personal _______________________________________________Fecha______________
****ESTA FORMA NO ESTÁ APROBADA POR EL DIRECTOR DE WCA Y SE PUEDE USAR
SOLAMENTE COMO GUÍA PARA COMPLETAR LA AUTORIZACIÓN EN INGLÉS. WCA NO
PERMITE ACEPTAR SU AUTORIZACIÓN USANDO ESTA FORMA****
11.4.4.9.18.2.C NMAC (rev. 1/07)
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