State of Maine Workers222 Compensation Board Limited Release of Medical/Health Care Information Related to Substance Abuse 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-B (eff. 9/1/18) Name: Date of Birth: SSN (last 4 digits): XXX-XX- Date of Injury/Illness: Notice 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. The Board222s forms may NOT be altered. Abuses may result in penalties. Notice to employeeto the identity, diagnosis, prognosis, or treatment of substance abuse, regardless of the date of injury, are relevant to 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, including Part 2 Program(s) to (name of facility/provider) release the records they have Voluntary: I understand I may choose not to complete this form. If I choose not to complete this form, my claim for benefits may be denied. Limited: I understand this form gives my health care providers permission to release only those health records related to the 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: 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 39Revocable: 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. I authorize release of my medical records to: (Name of Recipient) Address of Recipient: 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