Limited Release Of Health Information (HIPAA) {C-3.3}

Limited Release of Health Information (HIPAA) State of New York - Workers' Compensation Board WCB Case No. (if you know it):___________________________ C-3.3 To Claimant: If you received treatment for a previous injury to the same body part or for an illness similar to the one described in your current Claim, fill out this form. This form allows the health care providers you list below to release health care information about your previous injury/ illness to your employer's workers' compensation insurer. The federal HIPAA law (Health Insurance Portability and Accountability Act of 1996) says you have a right to get a copy of this form. If you do not understand this form, talk to your legal representative. If you do not have a legal representative, the Advocate for Injured Workers at the Workers' Compensation Board can help you. Call: 800-580-6665. To Health Care Provider: A copy of this HIPAA-compliant release allows you to disclose health information. If you send records to the employer's workers' compensation insurer in response to this release, also mail copies to the Claimant's legal representative. (If no legal representative is listed below, send copies to the Claimant.) Health care providers who release records must follow New York state law and HIPAA. This release is: Voluntary. Your health care provider(s) must give you the same care, payment terms, and benefits, whether you sign this form or not. Limited. It gives your health care provider(s) permission to release only those health records that are related to the previous illness/condition you describe below. Temporary. It ends when your current claim for compensation is established or disallowed and all appeals are exhausted. Revocable. You can cancel this release at any time. To cancel, send a letter to the health care provider(s) listed on this form. Also, send a copy of your letter to your employer's workers' compensation insurer and the Workers' Compensation Board. Note: You may not cancel this release with respect to medical records already provided. For records only. It gives your health care provider(s) listed on this form permission to send copies of your health care records to your employer's workers' compensation insurer. This form does NOT allow your health care provider(s) to release the following types of information: HIV-related information Psychotherapy notes Alcohol/Drug treatment Mental Health treatment (unless you check below) Verbal information (your health care providers may not discuss your health care information with anyone) Any medical records released will become part of your workers' compensation file and are confidential under the Workers' Compensation Law. A. YOUR INFORMATION (Claimant) 1. Name:__________________________________________________________________ 2. Social Security Number:______-_____-______ 3. Mailing Address: _________________________________________________________________________________________________ 4. Date of Birth: ______/______/______ 5. Date of the current injury/illness: ______/_______/_______ 6. Current injury/illness, including all body parts injured:_____________________________________________________________________ ______________________________________________________________________________________________________________ 7. Your legal representative's name and address (if any):___________________________________________________________________ ______________________________________________________________________________________________________________ Check here if you allow your health care provider(s) to release mental health care information. B. YOUR HEALTH CARE PROVIDER(S) (If more than 2 providers, attach their contact information to this form.) 1. 3. 4. 6. Provider:_________________________________________________________________ 2. Phone Number: (______)_______________ Mailing Address: _________________________________________________________________________________________________ Other provider (if any):_______________________________________________________5. Phone Number: (______)_______________ Mailing Address:_________________________________________________________________________________________________ C. READ AND SIGN BELOW. I hereby request that the health care provider(s) listed above give my employer's workers' compensation insurer copies of health records related to the previous injury/illness described above. ____________________________________________________________________________________________________________ Claimant's signature Date If the claimant is unable to sign, the person signing on his/her behalf must fill out and sign below: ______________________________________________________________________________________________________________ Your name Relationship to Claimant Signature Date C-3.3 (9-08) Versión en español al reverso de la forma. www.wcb.state.ny.us American LegalNet, Inc. www.FormsWorkflow.com Divulgación limitada de información sobre la salud (HIPAA) Estado de NuevaYork - Junta de Compensación Obrera (WCB) WCB Case No. (if you know it) (Número de caso WCB [si lo sabe]) C-3.3 Al reclamante: Si usted recibió tratamiento por una lesión anterior en la misma parte del cuerpo o por una enfermedad similar a la que motiva ahora su reclamación, complete este formulario. Este formulario les permite a los proveedores de salud que usted señala a continuación divulgar a la compañía de seguros de compensación obrera de su empleador la información sobre su salud relacionada con su lesión/enfermedad anterior. La Ley federal HIPAA (Ley de portabilidad y responsabilidad del seguro de salud de 1996) establece que usted tiene derecho a recibir una copia de este formulario. Si no comprende este formulario, hable con su representante legal. Si no tiene un representante legal, el Representante de los obreros lesionados de la Junta de Compensación Obrera puede ayudarlo. Llame al 800-580-6665. Al proveedor de salud: Una copia de esta divulgación, redactada según lo que establece la ley HIPAA, le permite divulgar información sobre la salud. Si envía los registros al asegurador de compensación obrera del empleador en respuesta a la presente divulgación, también debe enviar por correo copias al representante legal del reclamante. (Si a continuación no se especifica un representante legal, envíe las copias al reclamante). Los proveedores de salud que divulgan los registros deben cumplir con las leyes del estado de Nueva York y la HI