FOOT AND ANKLE CENTER OF ILLINOS

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.

PATIENT INFORMATION

Name

Date of Birth

Social Security #

Date of Injury

Body Part Injured

EMPLOYER

Name

Address

Phone #

Contact Person

WORKERS' COMPENSATION INSURANCE

Carrier Name

Address

Claim #

Adjuster

Insurance/Adjuster Phone

PERSONAL HEALTH INSURANCE

Group Name

Group Number

ID #

Phone #

Do you have an attorney?

Yes No

Do you plan on retaining an attorney?

Yes No

Attorney Name & Address

Phone #

Fax #

I, the undersigned, hereby authorize the use and disclosure of my health information (please check all that apply)

Upcoming appointment information

Faxing of medical records or reports

Off-work notices

Office notes

Work restrictions

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.

Patient Signature (Legal Guardian if under 18)

Date

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

ACCOUNT #

DATE OF SERVICE

Your information will be encrypted.