DOL FORM 7 (Rev. 1/12) State of Vermont Department of Labor Workers' Compensation Division PO Box 488 Montpelier, VT 05601-0488 (802) 828-2286 State File No.: Ins. Co. File No.: VERMONT WORKERS' COMPENSATION MEDICAL AUTHORIZATION NOTE: Title 21 VSA §655a requires all providers to utilize and comply with this medical release authorization form when seeking or providing medical information relative to a workers' compensation claim. Workers Compensation claims are expressly exempted from the terms and provisions of the Health Insurance Portability and Accountability Act of 1996 (HIPAA), 45 CFR 164.512(1). A copy of 21 VSA §655a is included with this form (see Page 2 of 2). TO: (Physician, Hospital or other medical practitioner) This, or a photocopy, will authorize you to release to (Department, Insurance Company, or Employer) at the following address: All medical information you may have relating to the treatment or diagnosis of my injury which occurred on or about , 20 Medical information relevant to the specific claim includes a past history of complaints or treatment of a condition similar to that presented in the claim or other conditions related to the same body part. Information that may be requested includes: (1) Minimum data to justify services and payment, including that on the standard paper 1500 form or electronic 837 form. (2) Office notes of the examination relating to the injury diagnosis or treatment. (3) Any other relevant provider records contained in the file. Name: Date of Birth: Date Signature Page 1 of 2 American LegalNet, Inc. www.FormsWorkFlow.com Page 2 of 2 Title 21: Labor Chapter 9: EMPLOYER'S LIABILITY AND WORKERS' COMPENSATION 21 V.S.A. § 655a. Release of relevant medical records by health care providers; department to oversee release and use of relevant medical information § 655a. Release of relevant medical records by health care providers; department to oversee release and use of relevant medical information (a) Health care providers examining or attending the examination of an injured worker pursuant to this chapter shall provide relevant medical records and reports as requested by the injured worker, the employer, or the department regarding the diagnosis, condition, or treatment of the worker, permanent impairment, or any restrictions or limitations on the worker's ability to work upon receiving a written medical release authorization from the injured worker. The authorization shall be on a form approved by the department. If the relevance of any medical information is disputed, the department shall determine whether the requested medical information is relevant. (b) Medical information relevant to the specific claim includes a past history of complaints or treatment of a condition similar to that presented in the claim or other conditions related to the same body part. Information that may be requested includes: (1) Minimum data to justify services and payment, including that on the standard paper 1500 form or electronic 837 form. (2) Office notes of the examination relating to the injury diagnosis or treatment. (3) Any other relevant provider records contained in the file. (c) An injured worker shall only be obligated to sign a medical record release authorization approved by the department. (d) Any medical information received by the employer or the insurance carrier that is found not to be relevant to the claim may not be used to deny or limit a claim. The commissioner may order that specific disclosure requests be denied or rescinded and may make such other interim orders as are appropriate. (e) Any medical information received in conjunction with a claim shall be used only for the purpose of advancing or defending a claim relating to the injury or of investigating a claim of false representation or of ensuring compliance with the workers' compensation statutes and rules. (Added 2011, No. 50, § 4.) American LegalNet, Inc. www.FormsWorkFlow.com