State of Maine Workers222 Compensation Board Limited Release of Medical/Health Care Information Related to Psychological Matters 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-A (eff. 9/1/18) Name: 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 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 mental health records related to: Mental health treatment and diagnosis/diagnoses 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 condition(s) listed above. This release authorizes the release of records dating from until twelve (12) months after the date I sign this form. This release authorizes my health care providerVoluntary: 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: 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 compensable. Revocable: 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.RIGHT TO REVIEW: You have the right to review your mental health records prior to the authorized release of the records. You may add material to your record in order to clarify information you believe is false, inaccurate or incomplete. Check this box if you want to review your records before they are released. By checking this box and signing below, I understand the review will be supervised and my review of the records prior to their release may delay the consideration of my claim. 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