Utah > Workers Compensation
Authorization To Disclose Release And Use Protected Health Information (Industrial Accidents) 308 - Utah
| Authorization To Disclose Release And Use Protected Health Information (Industrial Accidents) Form. This is a Utah form and can be used in Workers Compensation . |
|
||||||
 Get this form for FREE as a print-only pdf |
|||||||
|
Print Form Form 308 I AUTHORIZATION TO DISCLOSE, RELEASE AND USE PROTECTED HEALTH INFORMATION (HIPAA COMPLIANT) PLEASE PRINT OR TYPE Requesting Party _______________________________ Address _______________________________________ _______________________________________ TO _______________________________________________ _______________________________________________ Telephone Number ______________ Fax _______________________ (Medical Providers as listed on Form 307) This authorization permits you to release a copy of records in your possession regarding any medical treatment and/or hospitalization of: Name of Patient _____________________________________ Social Security Number ______________________________ Date(s) of Injury/Occupational Disease _________________ I AUTHORIZE you to disclose any information and records regarding the above named individual in your possession. This includes but is not limited to, your medical findings, diagnosis, treatment, treatment summaries, prognosis, clinic notes, diagnostic reports or radiology films, physical therapy records, pharmacy records, or any other health information in your records for the past 10 years (15 years if claim is being adjudicated). I understand that based on the information released it may include information related to any substance abuse. I UNDERSTAND that the information furnished may be used to evaluate and verify my claim for benefits for a work related injury or occupational disease. The information obtained is relevant to a workers' compensation claim(s) and may be used by persons or organizations performing a service related to, or adjudicating the claim(s). THIS AUTHORIZATION will expire 90 days following a resolution of the workers' compensation claim(s) but may be revoked by signator in writing to the requesting party. Revocation of this authorization will not be valid if the requesting party has taken action in reliance upon such authorization. Please note that the information disclosed or used pursuant to this authorization may be subject to re-disclosure and would, therefore, no longer be protected under the terms of the HIPAA privacy rule. A PHOTOSTATIC COPY of this authorization shall be deemed to have the same authority as the original. Date of Birth ________________________ I hereby certify that I have read the provisions in this authorization. I understand and agree to its terms, and authorize disclosure of the information described above. ________________________________________________ Patient ______________________________ Date Please fax or mail back to the requesting party at the above fax/address. Official Form 308 I State of Utah Labor Commission Division of Industrial Accidents 160 East 300 South P.O. Box 146610 Salt Lake City, UT 84114-6610 Telephone: (801) 530-6800 Fax: (801) 530-6804 Toll Free: (800) 530-5090 www.laborcommission.utah.gov American LegalNet, Inc. www.FormsWorkFlow.com
|
|||||||
