State of Maine Workers222 Compensation Board Limited Release of Medical/Health Care Information The State of Maine provides equal opportunity in employment and programs. Auxiliary aids and services are available to individuals with disabilities upon request. For assistance with this form, contact the ADA Coordinator at the Maine Workers222 Compensation Board. Telephone: (888) 801-9087 or TTY Maine Relay 711. WCB-220 (eff. 9/1/18) Name: Date Birth: SSN (last 4 digits): XXXNotice to employer/insurer/employee representative: You may only use forms adopted by the State of Maine Workers' Compensation Board for the release of protected medical/health care information to an employer or its insurer. The Board222s forms may NOT be altered. Abuses may result in penalties. Notice to employee: The employer/insurer contends your health care provider222s medical records, regardless of the date of injury, meaning all records relating to the diagnosis, treatment and care, including X are needed to determine whether your claim for benefits pursuant to the Workers222 Compensation Act (Title 39-A) is compensable. This release authorizes any and all health care providers to release the records, regardless of the date of injury, they have related to the diagnosis, treatment and care, including X-rays, of the body part(s) and/or condition(s) listed above. This release authorizes the release of records dating Voluntary: I understand I may choose not to complete this form. If I choose not to complete this form, mdenied. Limited: I understand this form gives my health care providers permission to release only those health records related to the body part(s) and/or condition(s) listed above. This form does NOT authorize oral communication with or by any health care provider with anyone other than me or my representative. Redisclosure: I understand the information provided pursuant to this release can be redisclosed for the limited purpose of determining whether my claim for benefits pursuant to the Workers222 Compensation Act (Title 39-A) is compensableRevocable: I understand I may revoke this authorization at any time in writing, but doing so may result in a loss of, or reduction in, entitlement to workers222 compensation benefits. I must revoke my authorization by completing and sending WCB Form 220-R to the recipient listed below. Note: You may not cancel this release with respect to medical records already provided. This authorization does NOT authorize the release of information regarding testing, treatment or counseling related to: Psychological matters; substance abuse; HIV/Aids and sexually transmitted diseases. I authorize release of my medical records to: Employee or Authorized Representative Signature Date: For purposes of this release, 223authorized representative224 has the same definition as set forth in 22 M.R.S.A. 247 1711-C(1)(A). American LegalNet, Inc. www.FormsWorkFlow.com