Maryland > Workers Compensation > Adjudication Claims
Authorization For Release Of Medical Information A25 - Maryland
| Authorization For Release Of Medical Information Form. This is a Maryland form and can be used in Adjudication Claims Workers Compensation . |
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WORKERS COMPENSATION COMMISSION AUTHORIZATION FOR RELEASE OF MEDICAL INFORMATION PURSUANT TO COMAR 14.09.01.10 REQUIRING THE DISCLOSURE OF MEDICAL INFORMATION IN A WORKERS COMPENSATION CLAIM TO: (Name of Record Holder) PATIENT/CLAIMANT NAME: | SS#: | DATE OF BIRTH: | DATE OF ACCIDENT: | | | | | | | | | I, hereby, authorize you to give to: (Name of Record Requestor) a copy of all information developed by you in my medical record regardin g the condition of the following part or parts of my body or my medical condition: (Specify part or parts of body or medical condition.) while under your observation or treatment or otherwise in your possession. This includes, but is not limited to, history, findings, office and patient charts and files, exam ination and progress notes, physical evidence prepared by you and any subsequent or future developments relat ing to my health or mental condition. This authorization is valid for up to one year from the date it is signe d and may be revoked at anytime. Disclosure of medical information pursuant to this authorization is NOT prohibited under the Health Insurance Portability and Accessibility Act ("HIPAA"). The Health Insurance Portability and Accessibility Act (HIP A A) at 45 CFR sect. 164.512 provides: a covered entity may disclose protected health information as authorized by and to the extent necessary to comply with laws relating to workers compensation or ot her similar programs, established by law, that provide benefits for work-related injuries or illnesses wit hout regard to fault. ________________________________________________ SIGNATURE of claimant/patient or authorized representative _____________________ DATE 10 East Baltimore Street . Baltimore, Maryland 21202-1641 410-864-5100 . Email: info@wcc.state.md.us . Web: http://www.wcc.state.md.us WCC Form A-25 (4/04)
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