WC-CATASTROPHIC REHAB RELEASE GEORGIA STATE BOARD OF WORKERS' COMPENSATION CATASTROPHIC REHABILITATION SUPPLIER AUTHORIZATION AND CONSENT TO RELEASE INFORMATION Patient Nam e: SSN or Board Tracking # Date of Injury Date of Birth Re: The Purpose of this document, or a photocopy of same, is to allow the above-stated entity, facility or medical practitioner to release information to in accordance with applicable State and Federal laws. Further, this document also allows the above stated rehabilitation supplier to gather and use information necessary to carry out his/her obligations pursuant to O.C.G.A. 34-9-200.1 and Board Rule 200.1. A. Medical Release: This release entitles the rehabilitation supplier to obtain all medical records, necessary to grant relief, effect a cure, or restore the employee to suitable employment under O.C.G.A. 34-9-200(a), from any medical practitioner who has examined, treated, or tested the employee or consulted about the employee’s physical or mental health or vocational status. The records obtainable include those for examination, treatmen t, testing or consultation concerning the employee as it relates to the injury date listed above. B. Use of Information: This form allows the above named rehabilitation supplier to use any and all health and vocational information obtained necessary to carry out the duties of the rehabilitation supplier as set forth in O.C.G.A. 34-9-200.1 or Board Rule 200.1. Copies of any records or documents provided to the employer/insurer shall be provided simultaneously to the employee or the employee’s counsel when represented. The patient completely releases the entity, facility, or medical practitioner from any and all liability which may result from the release of such information. This release is in compliance with Federal regulations (42 CFR Part 2), and the Health Insurance Portability and Accountability Act of 1996 (HIPPA). 45 CFR 164.512(1) which reads as follows: The 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 from work-related illnesses or injury without regard to fault. Anyone who receives information under this document receives the same under all protection of Federal and Stat e law inuring the patient. C. Claimant’s Right to Private Examination: The employee has the right to a private physical examination and/or consultation with the medical provider. The employee agrees that the case manager may meet with the physician and employee following a private physical examination and/or consultation, provided that, upon specific request, the claimant’s attorney is given reasonable notice of the appointment date and time. This release and consent shall expire at the close of rehabilit ation, upon the dismissal of the rehabilitation supplier, and/or upon written notice of revocation by the employee, whichever is earlier. Signature Date Supplier Witness Date Date A photostatic copy of this authorization w ill be considered as effective and valid as the original. IF YOU HAVE QUESTIONS PLEASE CONTACT THE STATE BOARD OF W ORKERS’ COMPENSATION AT 404-656-3818 OR 1-800-533-0682 OR VISIT http://www.sbwc.georgia.gov WILLFULLY MAKING A FALSE STATEMENT FOR THE PURPOSE OF OBTAINING OR DENYING BENEFITS IS A CRIME SUBJECT TO PENALTIES OF UP TO $10,000.00 PER VIOLATION (O.C.G.A. REVISION . 07/2011 34-9-18 AND 34-9-19). WC-CATASTROPHIC REHAB RELEASE American LegalNet, Inc. www.FormsWorkFlow.com