RELEASE OF COUNSELING, PSYCHOLOGICAL, PSYCHIATRIC, OR ALCOHOL/DRUG/SUBSTANCE ABUSE TREATMENT RECORDS OR INFORMATION (For cases involving psychological conditions or substance abuse) Re: ____________________________v. _________________________________ Alaska Worker's Compensation Claim No. _________________________ TO: Any psychologist, counselor, or psychiatrist, clinic, health insurer, government agency, insurer, employer or other person, entity, firm, or organization having custody of counseling, psyc hological, psychiatric, or alcohol/drug/substance abuse treatment records or information pertaining to me, the undersigned person. I, the undersigned person, give my consent and authorize you to release the following records or information in your possession to _____________________________________________________, the defendants, or representative of the defendants, in the above Workers' Compensation Claim filed by me. I also consent and authorize, but do not necessarily request, you to discuss the following records or information pertaining to me with the defendant or the defendant's representative. Counseling, psychological, psychiatric, or alcohol/drug/substance abuse treatment records or information relating to the treatment of my injury or illness at work, and the following diagnoses or conditions, chief complaints and/or symptoms: ______________________________________________________ ____________________________________________________________________________________________ This authorization releases records from ___________________ to the present. You should interpret the terms "counseling, psychological, psychiatric, or alcohol/drug/substance abuse treatment records or information" broadly to inc lude records, reports, notes, chart notes, letters, test reports or results, bills, and referral letters in your possession, whether generated by you or received from a third party. This release of information is intended to include records maintained in my maiden or other names as follows: _____________________________________________________________________. Please consider a photostatic copy of this authorization to release records to be as effective and valid as the original signed by me. This release, and all authority to disclose information pertaining to me, shall expire on __________________ (one year from the date of the signature below), unless earlier revoked by me in writing. Signature_______________________________________ Dated this ____ day of ___________________, 20__ MY PRINTED NAME: ______________________________________ Under AS 23.30.107, an employee must provide written release of medical and rehabilitation information relating to the injury. Parties should informally resolve dispu tes over what is relevant. Only if informal resolution is impossible, an employee may petition for a prehearing and a protective order within 14 days after receipt of the request to sign the release. Failure to either obtain a protective order or to sign a release will result in suspension, and possible forfeiture, of compensation. AS 23.30.108. TO HEALTH CARE PROVIDERS: 45 C.F.R. 164.512(l) exempts workers' compensation disclosures from HIPAA. (revised 06/2003 American LegalNet, Inc. www.USCourtForms.com