State of Maine Workers222 Compensation Board Revocation of 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 Name: Date of Birth: SSN (last 4 digits): XXX-XX- Notice to employee: This revocation must be sent to the recipient who requested access to your records. You should keep a copy of the signed form for your records. I am revoking the limited release of medical/health care information (Name) signed by me on and provided to . Employee or Authorized Representative Signature For purposes of this revocation, 223authorized representative224 has the same definition as set forth in 22 M.R.S.A. 247 1711-C(1)(A). Notice to employer/insurer/employee representative: Within 14 days after receipt of this form you must forward a copy to all health care providers to whom you provided the limited release signed by the employee on the date listed above. Notice to employee: Your health care provider may not receive your revocation immediately and will continue to release your records until they receive a copy of this revocation. You should provide a copy of this revocation to your health care providers as soon as possible. You should also keep a copy of this revocation for your records.