CLAIMANTS AUTHORIZATION TO DISCLOSE HEALTH INFORMATION (Pursuant to HIPAA) INSTRUCTIONS To the Claimant: The Health Insurance Portability and Accountability Act of 1996 (HIPAA) set standards for guaranteeing the privacy of individually identifiable health information and the confidentiality of patient medical records. By completing and signing this form, you authorize your health care provider to file medical reports with the parties that you choose (such as the Workers Compensation Board, your employers insurance carrier, your attorney or representative, etc.) by checking the appropriate boxes below. You have the right to refuse to sign this Authorization. If you sign, you have the right to revoke this Authorization at any time by mailing a request to revoke to the health care provider. You have the right to receive a copy of this Authorization. IMPORTANT: Failure to execute this authorization may interfere with your ability to obtain workers compensation benefits. CLAIMANTS NAME CLAIMANTS SOCIAL SECURITY NUMBER CLAIMANTS DATE OF BIRTH LIST ALL WCB CASE NUMBER(S) AND CORRESPONDING DATE(S) OF ACCIDENT FOR WHICH YOU ARE GRANTING AUTHORIZATION I, __________________________________________________________, hereby authorize my treating health provider, Claimants Name _____________________________________________________, to disclose the following described health information: Health Providers Name _________________________________________________________________________________________________ _________________________________________________________________________________________________ _________________________________________________________________________________________________ This information can be disclosed to the following parties: (check all that apply; give names and addresses, if known) New York State Workers Compensation Board My current/former employer _______________________________________________________________________ Workers compensation insurance carrier(s) __________________________________________________________ Third-party administrator ___________________________________________________________________________ My attorney/licensed representative __________________________________________________________________ The Uninsured Employers Fund (this fund is responsible for paying the medical bills and lost wage benefits when an employer is uninsured.) Special Funds Conservation Committee (for cases under Section 25-a or 15-8 of the Workers Compensation Law) Section 25-a: If your claim is being reopened after being previously closed, the Special Fund for Reopened Cases may be responsible for paying your medical bills and lost wage benefits. Section 15-8: If you had a medical condition that existed prior to this injury, the Special Fund for Second Injuries may be responsible for reimbursing your employers insurance carrier after a period of time has elapsed. Redisclosure: I understand that once the above-referenced health care provider discloses health information based on this Authorization, that health information is no longer protected by HIPAA and the Privacy Rule. Expiration Date: This Authorization expires upon the final closing of the workers compensation claim(s) for which it is executed. I have had the opportunity to review and understand the content of this Authorization. By signing this Authorization, I confirm that it accurately reflects my wishes. _____________________________________ ______________________________________ ______________________ Printed Name of Claimant or Legal Representative Signature of Claimant or Legal Representative Date If Authorization signed by a legal representative on behalf of claimant, state relationship to claimant_____________________________________________and basis for authority (e.g. claimant is a minor; patient is deceased and representative is the claimant in a workers compensation proceeding or represents the estate) ___________________________________________________________________________________________________________________________TO THE HEALTH PROVIDER: Keep the original of this Authorization on file. A copy must be given to the patient/claimant upon request. DO NOT SEND TO THE NEW YORK STATE WORKERS COMPENSATION BOARD. HIPAA-1 (12-03) www.wcb.state.ny.us