Maine > Workers Compensation
Limited Certificate Authorizing Written Release Of Medical Or Health Care Information WCB-220 - Maine
| Limited Certificate Authorizing Written Release Of Medical Or Health Care Information Form. This is a Maine form and can be used in Workers Compensation . |
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LIMITED CERTIFICATE AUTHORIZING WRITTEN RELEASE OF MEDICAL / HEALTH CARE INFORMATION STATE OF MAINE WORKERS'COMPENSATION BOARD (03/2<(( '$7( 2) ,1-85< %5,() '(6&5,37,21 2) %2'< 3$576 ,1-85(' $''5(66 62&,$/ 6(&85,7< 180%(5 XXX-XX- (03/2<(5 ,1685(5 $77251(< $''5(66 $''5(66 $''5(66 , KHUHE\ DXWKRUL]H WKH DERYH HPSOR\HU LQVXUHU RU WKHLU DWWRUQH\ WR REWDLQ IURP DQ\ KRVSLWDO SK\VLFLDQ RVWHRSDWK FKLURSUDFWRU RU RWKHU KHDOWK FDUH SURYLGHU DIWHU SD\PHQW WR WKH SURYLGHU RI D UHDVRQDEOH IHH DQ\ ZULWWHQ LQIRUPDWLRQ RQO\ ZKLFK LV RU KDV EHHQ SUHSDUHG LQ FRQQHFWLRQ ZLWK P\ H[DPLQDWLRQ RU WUHDWPHQW UHJDUGOHVV RI GDWH ZKLFK UHODWHV WR P\ BBBBBBBBBBBBBBBBBBBBBBBBBBLH ERG\ SDUW DQGRU FRQGLWLRQ RQO\ 7KLV FHUWLILFDWH RI DXWKRUL]DWLRQ UHPDLQV YDOLG DQG PXVW EH KRQRUHG IRU DV ORQJ DV , FRQWLQXH WR PDNH DQ\ FODLP IRU FRPSHQVDWLRQ DQ\ FRPSHQVDWLRQ SD\PHQW VFKHPH UHPDLQV LQ HIIHFW RU , UHFHLYH FRPSHQVDWLRQ 7KLV FHUWLILFDWH RI DXWKRUL]DWLRQ GRHV 127 SHUPLW WKH UHOHDVH RI DQ\ LQIRUPDWLRQ UHJDUGLQJ SV\FKRORJLFDO VXEVWDQFH DEXVH VH[XDOO\ WUDQVPLWWHG GLVHDVH WUHDWPHQW WHVWLQJ RU FRXQVHOLQJ DQG GRHV 127 DXWKRUL]H RUDO FRPPXQLFDWLRQ ZLWK RU E\ DQ\ KHDOWK FDUH SURYLGHU BBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBB (03/2<(( 6,*1$785( BBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBB '$7( NOTICE TO THE EMPLOYEE <28 +$9( '$<6 )520 5(&(,37 2) 7+,6 &(57,),&$7( 72 6,*1 $1' 5(7851 ,7 72 7+( (03/2<(5 25 ,1685(5 )$,/85( 72 6,*1 $1' 5(7851 7+,6 &(57,),&$7( 0$< 5(68/7 ,1 $ 6863(16,21 2) $&7,9,7< 21 <285 &/$,0 )25 &203(16$7,21 25 ,) <28 $5( &855(17/< 5(&(,9,1* &203(16$7,21 <285 3$<0(176 2) &203(16$7,21 0$< %( 6863(1'(' 817,/ <28 6,*1 $1' 5(7851 7+,6 &(57,),&$7( 7+,6 ,6 7+( $87+25,=(' )250 )25 7+( 5(/($6( 2) 0(',&$/ $1' 5(/$7(' ,1)250$7,21 81'(5 7+( 0$,1( :25.(56 &203(16$7,21 $&7 $1' ,6 ,17(1'(' 72 6833/(0(17 7+( 5,*+76 72 6(&85( 0(',&$/ ,1)250$7,21 6(7 )257+ %< 7,7/( $ 2) 7+( 0$,1( 5(9,6(' 67$787(6 $1127$7(' $1' &+$37(5 6(&7,21 2) 7+( %2$5' 6 58/(6 $1' 5(*8/$7,216 7+( 67$7( 2) 0$,1( '2(6 127 ',6&5,0,1$7( 21 7+( %$6,6 2) ',6$%,/,7< ,1 $'0,66,21 72 $&&(66 72 25 23(5$7,21 2) ,76 352*5$06 6(59,&(6 25 $&7,9,7,(6 7+,6 )250 ,6 $9$,/$%/( ,1 $/7(51$7,9( )250$7 )25 )857+(5 $66,67$1&( &217$&7 7+( 0$,1( :25.(56ΒΆ &203(16$7,21 %2$5' $'$ &225',1$725 7(/(3+21( 25 77< 0DLQH 5HOD\ :&% HII American LegalNet, Inc. www.FormsWorkFlow.com
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