Fill and Sign the York Childrens Foundation Form

MEDICAL AUTHORIZATION RE: Name: ____________________________________________________________ Claim Number: ______________________________________________________ DOB: ______________________________________________________________ In accordance with the provisions of the Privacy Rule for the Health Insurance Portability and Accountability Act (HIPAA), YOU ARE HEREBY AUTHORIZED TO RELEASE TO Travelers Indemnity Company and its Property/Casualty affiliates (hereinafter “Travelers”) or Constitution State Services, LLC PO Box 682165 Franklin TN 37068 Fax: 877/786-5582 or any representative acting on its behalf, including my employer, and permit examination and/or copying of: Any and all hospital records, medical records, psychological or psychiatric records, x-ray films, other similar studies and their reports, all tests of any type and character and their reports, statements of charges and any and all records of medical care, history, condition, treatment, diagnosis, prognosis, etiology, work restrictions, impairment or expense in your possession or control pertaining to the undersigned. You are also authorized to discuss my injuries, physical condition, treatment, care, restrictions, impairment, causation and related issues and to furnish a written report regarding same. The purpose for releasing this information is: (A) To facilitate the evaluation of my claim for Workers’ Compensation benefits. (B) To permit said disclosed information to be used in preparation for and admitted into evidence at any hearing on my claim for said benefits. A photocopy of this authorization shall be as valid as the original. I understand that I may revoke this authorization at any time but to do so I must advise Travelers and/or Constitution State Services LLC in writing. This authorization is valid for the duration of this claim unless revoked. You and Travelers and/or Constitution State Services, LLC are hereby released from any and all liability or responsibility that could or might result because of the disclosure of any information pursuant to this authorization. ______________________ DATE ____________________________________ SIGNATURE ____________________________________ PRINT NAME