Limited Release Of Medical Health Care Information Related To Substance Abuse {WCB-220-B}

WCB-220-B - LIMITED RELEASE OF PROTECTED MEDICAL/HEALTH CARE INFORMATION RELATED TO SUBSTANCE USE DISORDER. This form from the State of Maine Workers’ Compensation Board is used to authorize the limited release of medical records related specifically to substance use disorder in connection with a workers’ compensation claim. It allows an employee to permit their health care providers, including those governed by 42 CFR Part 2 (confidentiality of substance use disorder patient records), to release records concerning the identity, diagnosis, prognosis, or treatment of substance use disorder to a specified recipient, such as an employer, insurer, or their representative. The release is time-limited, allowing disclosure from a specific past date until 30 months after the form is signed. The form is voluntary and revocable, though refusal or revocation may affect the employee’s eligibility for benefits. It restricts the use of the released records solely to evaluating the compensability of the workers’ compensation claim and prohibits oral communications unless separately authorized. Health care providers must comply with requests under this release within 30 days. www.FormsWorkflow.com