I, or my authorized representative, request and authorize that health information regarding my care and treatment, and information maintained in workers’ compensation records, be released to the person(s)specified in Item 6, below:
I understand that:
1. This authorization includes disclosure of information, if any, relating to alcohol and drug abuse, mental health treatment, except psychotherapy notes, and confidential HIV related information. In the event the confidential information described below includes any of these types of information, I specifically authorize release of such information to the person(s) indicated in Item 6.
2. The law may prohibit the recipient from redisclosing Workers’ Compensation Records (including Workers’ Compensation Board records), HIV-related, alcohol or drug treatment, or mental health treatment information, (collectively “confidential information”) without my authorization unless permitted to do so under federal or state law. However, I specifically authorize the person(s) indicated in Item 6 to re-disclose this confidential information to ABC Company and/or any of their representatives, including organizations providing claims management service sand claim advocates retained by ABC Company.
3. I have the right to revoke this authorization at any time except to the extent that action has already been taken based on this authorization.
4. Signing this authorization is voluntary. My treatment, payment, enrollment in a health or insurance plan, or eligibility for benefits will not be conditioned on my authorization of this disclosure.
5. I understand that an authorization releasing workers’ compensation information to prospective employers is not valid. I understand that this authorization is not being used to release workers’ compensation information to prospective employers in connection with assessing fitness or capability of employment.
6. Identity of Entity or Person(s) to whom this information will be sent: XYZ Company and affiliates.