Code of Maine Rules › 90 - INDEPENDENT AGENCIES › 351 - WORKERS' COMPENSATION BOARD › Chapter 12 - FORMAL HEARINGS › Appendix 351-12-III - Certificate Authorizing Written Release of Limited Medical / Health Care Information

Current through 2024-29, July 17, 2024
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)