Fill and Sign the Release of Medical Information Alaska Department of Labor

revised 06/2003 RELEASE OF MEDICAL INFORMATION Re: ____________________________v. _________________________________ Alaska Worker's Compensation Claim No. _________________________ TO: Any doctor, chiropractor, hospital, clinic, health insurer, physical therapist, gov ernment 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 auth orize, 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 interpr et 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 result s, 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 pert aining 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 reso lution 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 disclosure s from HIPAA.