Authorization To Obtain And Or Disclose Health Information

AUTHORIZATION TO OBTAIN AND/OR DISCLOSE HEALTH INFORMATION. This form is used in Connecticut Workers’ Compensation cases to permit the release of a patient’s protected health information (PHI). This form allows a patient to authorize a healthcare provider to share relevant medical records, reports, and treatment information with a specified person or entity, including attorneys and representatives involved in a workers’ compensation claim. It requires details such as the provider, recipient, dates of service, and specific body parts or conditions. The form also includes special authorization for sensitive records, such as mental health, substance abuse, HIV, reproductive health, and genetic information. It must be signed by the patient or authorized representative and may be revoked at any time. www.FormsWorkflow.com