C.M.R. 90, 351, ch. 12, app 351-12-III
STATE OF MAINE WORKERS'COMPENSATION BOARD
Notice to employer/insurer : This is the ONLY form authorized by the State of Maine Workers' Compensation Board for the release of protected medical/health care information. This form may NOT be altered. Abuses of this form will be referred to the Workers' Compensation Abuse Investigation Unit.
To be completed by employer/insurer:
This authorization is for use or disclosure of protected health information pertaining to:
Name: Date of injury:
Date of Birth: SSN (last 4 digits): XXX-XX-
List body parts and/or conditions that employer/insurer contends are relevant for determination of compensability and disability:
________________________________________________________________________
Notice to employee : The employer/insurer contends that the medical records and information, pre-existing and/or subsequent to your claimed workplace injury are relevant for determination of compensability and disability. You have 14 days from receipt of this certificate to complete and return it to the employer/insurer.
This form does NOT allow your health care provider(s) to discuss your health care information with anyone nor does it allow for the release of records related to psychological matters, substance abuse, HIV, or sexually transmitted diseases.
In the event that the employer/insurer contends that medical or counseling records related to psychological matters, substance abuse, HIV, or sexually transmitted disease matters are relevant to issues in the workers' compensation case, it may obtain such specific additional medical and other information as agreed upon among represented parties. In all other cases, specific additional medical and other information may be requested on written motion to the Hearing Officer showing the need for the information. The Hearing Officer may authorize the release of this information subject to appropriate terms and conditions as to reasonable protection of confidentiality.
The State of Maine provides equal opportunity in employment and programs. Auxiliary aids and services are available to individuals with disabilities upon request. For assistance with this form, contact the ADA Coordinator at the Maine Workers' Compensation Board. Telephone: (888) 801-9087 or TTY 711.
To be completed by employee:
I hereby authorize the employer/insurer, or its authorized representative to obtain from any health care provider, any written information which is or has been prepared in connection with my examination or treatment regardless of date which relates to the following body parts and/or conditions:
________________________________________________________________________
(List body parts and/or conditions from those identified above that are agreed to)
I understand that I may choose not to complete this form or withdraw my authorization at any time, however doing so may result in a loss of or reduction in entitlement to workers' compensation benefits. This certificate of authorization remains valid and must be honored for as long as I continue to make any claim for compensation, any compensation payment scheme remains in effect, or I receive compensation. This certificate of authorization does NOT permit the release of any information regarding body parts and/or conditions not listed by me, nor does it permit the release of any psychological, substance abuse, HIV, or sexually transmitted disease treatment, testing, or counseling records. This certificate of authorization does NOT authorize oral communication with or by any health care provider.
SIGNATURE: DATE:
Mailing Address:
City: State: Zip:
Legal Representative's Name and address (if any):
Notice to Health Care Provider: Authorization is not required from the employee or the employee's representative for the release of medical information pertaining to a claimed workers' compensation injury or disease regardless of whether the claimed injury or disease is denied.
A copy of this HIPAA-compliant release allows you to disclose health information regarding the health records related to the body part(s) and/or conditions listed by the employee. If you send records to the employer/insurer, you must also send copies to the claimant's legal representative listed above (if no legal representative is listed, copies must be sent to the claimant. Health care providers who release records must do so in accordance with applicable state and federal law.
Copies must be furnished within 10 business days from receipt of a properly completed form. The maximum fee for copies shall be $5 for the first page and 45¢ for each additional page, up to a maximum of $250.00. The copying charge shall be paid by the party requesting the records.
The State of Maine provides equal opportunity in employment and programs. Auxiliary aids and services are available to individuals with disabilities upon request. For assistance with this form, contact the ADA Coordinator at the Maine Workers' Compensation Board. Telephone: (888) 801-9087 or TTY 711.
WCB-220 (eff. 1/1/15)
C.M.R. 90, 351, ch. 12, app 351-12-III