State of Maine Workers222 Compensation Board Limited Release of Medical/Health Care Information Related to HIV/AIDS and Sexually Transmitted Diseases 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-C (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 employee: The employer/insurer/employee representative contends your health care providers Your HIV infection status, including the results of an HIV test The diagnosis, treatment and care of sexually transmitted diseases 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 they have related to the diagnosis, treatment and care of the condition(s) listed above, regardless of the date of injury. This release authorizes the release of records dating from until thirty (30) months after the date I sign this formVoluntary: I undersand 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 the medical records related to the condition(s) indicated above. This form does NOT authorize oral communication with or by any health care provider 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 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 recipien Potential Implications of Release: Releasing this information may have implications. Positive implications may include giving you more complete care. Negative implications may include discrimination if the data is misused. IMPORTANT NOTICE: By signing this form I understand that I am authorizing the release of my medical records related to my HIV infection status and/or my medical records regarding diagnosis, treatment and care of sexually transmitted diseases. I authorize release of my medical records toEmployee 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