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Maryland Authorization For Release of Medical Information

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This form is provided by Maryland Workers' Compensation Commission for the medical information release regarding the medical care and treatment necessary to be administered.

Maryland Authorization For Release of Medical Information
Maryland Authorization For Release of Medical Information
WORKERS' COMPENSATION COMMISSION
AUTHORIZATION FOR RELEASE OF MEDICAL INFORMATION
PURSUANT TO COMAR 14.09.01.10 REQUIRING THE DISCLOSURE OF
MEDICAL INFORMATION IN A WORKERS’ COMPENSATION CLAIM
TO:
(Name of Record Holder)
PATIENT/CLAIMANT NAME: | SS#: | DATE OF BIRTH: | DATE OF ACCIDENT:
| | |
| | |
| | |
I, hereby, authorize you to give to:
(Name of Record Requestor)
a copy of all information developed by you in my medical record regarding the condition of the
following part or parts of my body or my medical condition:
(Specify part or parts of body or medical condition.)
while under your observation or treatment or otherwise in your possession. This includes, but is not
limited to, history, findings, office and patient charts and files, examination and progress notes, physical
evidence prepared by you and any subsequent or future developments relating to my health or mental
condition. This authorization is valid for up to one year from the date it is signed. I understand
that I may revoke this authorization in writing at any time.
Disclosure of medical information pursuant to this authorization is NOT prohibited under the Health
Insurance Portability and Accessibility Act ("HIPAA").
The Health Insurance Portability and Accessibility Act (“HIP A A) at 45 CFR sect. 164.512
provides: “a covered entity may disclose protected health information as authorized by and to the extent
necessary to comply with laws relating to workers’ compensation or other similar programs, established
by law, that provide benefits for work-related injuries or illnesses without regard to fault.”
________________________________________________
SIGNATURE of claimant/patient or authorized representative
_____________________
DATE
10 East Baltimore Street
.
Baltimore, Maryland 21202-1641
410-864-5100
.
Email: [email protected]
.
Web: http://www.wcc.state.md.us
WCC Form A-25 (6/10/05)
CLICK HERE TO CLEAR THE FORM
Maryland Authorization For Release of Medical Information