Workers' Compensation Authorization Form
Effective April 15, 2003, HIPAA regulations went into effect. For workers' compensation purposes, we require specific authorization from the patient in order to release information.
WORKERS' COMPENSATION INSURANCE
PERSONAL HEALTH INSURANCE
By signing below I understand my health information will be used/disclosed to facilitate payment of my liability claim.
DISCLAIMER: By typing your name below, you are signing this application electronically. You agree that your electronic signature is the legal equivalent of your manual signature on this application.
This authorization will be valid only for the workers' compensation injury noted above. This authorization may be revoked, with written or verbal notification, except to the extent that information may be released prior to your notification to void authorization.
OFFICIAL USE ONLY
Your information will be encrypted.