STATE OF CONNECTICUT WORKERS’ COMPENSATION COMMISSION AUTHORIZATION FOR RELEASE OF MEDICAL RECORDS BY A HOSPITAL/PROVIDER FOR THE PURPOSE OF ADMINISTERING A CONNECTICUT WORKERS’ COMPENSATION CLAIM FOR BENEFITS PATIENT NAME: _________________________________________ DATE OF BIRTH: ________________ (PLEASE PRINT NAME) BODY PART(S): ____________________________________________________________________________ I, the undersigned, authorize: __________________________________________________________________ (HOSPITAL/PROVIDER) to disclose, orally or in writing, protected health information [PHI] to: ____________________________________________________________________________________________ (PERSON OR ENTITY TO WHOM INFORMATION IS TO BE DISCLOSED) and its attorneys and/or representatives. The PHI to be disclosed is relevant medical records and reports relating to my medical treatment/consultation/examination and/or diagnostic procedures performed at the above-named medical facility and which pertain to an injury/occupational disease for which I am claiming benefits under the Connecticut Workers’ Compensation Act. I understand the information disclosed based on this authorization may include mental health treatment records and information regarding HIV/AIDS status, treatment or testing. INFORMATION RELATING TO TREATMENT FOR ALCOHOL AND DRUG ABUSE WILL NOT BE RELEASED WITHOUT MY SPECIFIC CONSENT in accordance with state and federal law. 1 I understand I have the right to inspect or copy the PHI to be disclosed as permitted under federal HIPAA law and state law. I UNDERSTAND THAT I HAVE THE RIGHT TO REFUSE TO SIGN THIS AUTHORIZATION. I UNDERSTAND THAT I HAVE THE RIGHT TO REVOKE THIS AUTHORIZATION. In order to revoke this authorization I may, at any time, send written notification to the above-named HOSPITAL/PROVIDER. I understand that my revocation of this authorization is ineffective to the extent that the above-named HOSPITAL/PROVIDER has relied on this authorization to disclose PHI relating to me. I UNDERSTAND THAT PHI DISCLOSED PURSUANT TO THIS AUTHORIZATION MAY BE REDISCLOSED BY THE PERSON OR ENTITY I HAVE IDENTIFIED ABOVE AND MAY NO LONGER BE PROTECTED FROM DISCLOSURE TO OTHERS BY FEDERAL OR STATE LAW. I understand that the above-named HOSPITAL/PROVIDER may not condition my treatment on whether I provide authorization for the requested use or disclosure. I UNDERSTAND THAT I HAVE THE RIGHT TO DETERMINE A DATE OR EVENT AT WHICH TIME THIS AUTHORIZATION EXPIRES. I am identifying the expiration date of this authorization to be COMPLETION OF WORKERS’ COMPENSATION LITIGATION AS EVIDENCED BY A STIPULATION OR FINDING AND AWARD/DISMISSAL, OR IN THE EVENT OF APPELLATE REVIEW, A FINAL DETERMINATION BY THE HIGHEST APPELLATE AUTHORITY TO WHOM AN APPEAL IS MADE. I further understand that federal HIPAA law does not require me to provide an authorization in this form as the purpose of this authorization relates to a Workers’ Compensation matter. However, I understand that as a practical matter, my authorization in this form may facilitate the processing and administration of my claim for Workers’ Compensation benefits. My signature below indicates that I have read and understand this Authorization and its terms. _________________________________________ ________________________________________ Signature of Patient Date 1 Any consent to release information pertaining to treatment for drug and alcohol abuse must conform to the requirements of state law and the federal regulations, e.g., Part 2 of Title 42 of the Code of Federal Regulations. Effective June 1, 2004/Revised April 30, 2009 American LegalNet, Inc. www.FormsWorkFlow.com