Iowa > Workers Compensation
Authorization For Release Of Information (Patient Waiver) 14-0043 - Iowa
|Authorization For Release Of Information (Patient Waiver) Form. This is a Iowa form and can be used in Workers Compensation .||
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AUTHORIZATION FOR RELEASE OF INFORMATION REGARDING CLAIMANTS SEEKING WORKERS COMPENSATION BENEFITS To any medical practitioner or institution, including but not limited to, ________________________ ________________________________________________________________________ ________ Name of Person Whose Records are Being Requested: ______________________________________ Maiden or Previous Name(s): _____________________________________________________________ Birthdate: _____________________ Social Security No: __________ - __________ - __ ________ I. AUTHORIZATION FOR RELEASE OF INFORMATION The undersigned hereby authorizes all health care providers and facilities and any other person or entity in possession of records concerning me to disclose and deliver to ________________________________________________________________________ __________________________________________________________________________________________________ ______ (name of individual, firm, or institution and address) hereinafter referred to as Recipient, all information, including all protected health information, from whatever source relating to the above-named person. I understand the information is being disclosed and may be used only for legal and/or litigation purposes relating to claims and/or suit against ______________________________________________________ and ____________________________________________________________________ . II. REDISCLOSURE I understand that if the person or entity that receives the information requested is not covered by federal or state privacy regulations or is not an individual or entity who has signed an agreement with such a person or entity agreeing to maintain the confidentiality of the information, the information described above may be redisclosed and will no longer be protected by la w. Iowa and/or federal law provides that I have a right to prohibit redisclosure of certain types of confidential medical information and further disclosure may not be had without my express written authorization, as indicated below. I further understand that the Recipient, WITHOUT FURTHER AUTHORIZATION, may redisclose said information to parties and their legal counsel, insurers, experts, potential experts, anyone against whom claim is or has been made, administrative agency and court official s hearing the claim, and any agents, employees, or representatives of any said persons. I SPECIFICALLY AUTHORIZE AND CONSENT TO THE DISCLOSURE AND REDISCLOSURE DESCRIBED ABOVE. Federal and/or State law specifically require that any disclosure or red isclosure of substance abuse, alcohol or drug, mental health, or AIDS-related information must be accompanied by the following written statement: This information has been disclosed to you from records protected by Federal confidentiality rules (42 CFR Part 2). Federal rules prohibit you from making any further disclosure of this information unless further disclosure is expressly permitted by the written consent of the person to whom it pertains or as otherwise permitted by 42 CFR Part 2. A general authorization for the release of medical or other information is NOT sufficient for this purpose. The Federal rules restrict any use of the information to criminally investigate or prosecute any alcohol or drug abuse patient. See also Chapter 228 of the Iowa Code and Chapter 141A of the Iowa Code and other applicable laws. <<<<<<<<<********>>>>>>>>>>>>> 2 III. SPECIFIC AUTHORIZATION FOR RELEASE OF INFORMATION PROTECTED BY STATE OR FEDERAL LAW I acknowledge that information to be released may include material that is protected by Federal and/or State law applicable to substance abuse, mental health, and/or AIDS-related information. I SPECIFICALLY AUTHORIZE the release of confidential information relating to: [Place YES or NO in ALL applicable boxes:] _____ Substance Abuse (Drug or Alcohol) Information from all health care providers and facilities and any other person or entity in possession of records concerning me. _____ Mental Health Information from all health care providers and facilities and any other person or entity in possession of records concerning me. _____ HIV or AIDS-related Information, Diagnosis, and test results from all health care providers and facilities and any other person or entity in possession of records concerning me. Furthermore, I S PECIFICA LLY A UTHORIZE disclosure and redisclosure of this confidential information t o all of t he persons referred to in s ect ion II above. In order for t he above information t o be releas ed, you mus t s ign here AND at the end of this form. _____________________________________________ ______________________ _______________ Signature of Patient or Legal Guardian or Personnel Date Representative, _________________________________________________________ Relationship, if NOT the patient I understand that this Authorization may be used to obtain information from health care providers, schools, former and current employers, providers of vocational rehabilitation services, the Social Security Administration, and the Iowa Department of Workforce Development. I understand that I have a right to inspect the disclosed information at any time. This Authorization is effective until the conclusion of a contested case on the claim. I understand that I may revoke this Authorization, except to the extent that action has already been taken in reliance upon it, by giving written notice to the health care provider or record keeper. A photocopy, or exact reproduction of this signed Authorization shall have the same force and effect as this original. I hereby authorize the release of information as indicated above. I HEREBY ACKNOWLEDGE THAT I HAVE RECEIVED A COPY OF THIS DOCUMENT. ________________________________________________ ___________________ __________________ Signature of Person Whose Records are Being Requested Date of sign ing ________________________________________________________________________ ________________ Street Address City/State/Zip Code _________________________________________________________ Relationship, if NOT the Person Whose Records Are Being Requested ___________________________________________________________ Print Name of Person or Persons Personal Representative 14-0043 (08/03) This form may be used in connection with claims under the jurisdiction of the Iowa Workers Compensation Commissioner.