Patient Name: _____________________ Date of Birth: _______________ SSN: ________________
I authorize the disclosure of all protected medical information for the purpose of workers’ compensation proceedings. I expressly request that all health plans and all health care providers identified above disclose full and complete protected medical information spanning the time period of __________________ to present and continuing, including the following:
- All medical records, including inpatient, outpatient and emergency room treatment, all clinical charts, reports, documents, correspondence, test results, statements, questionnaires/histories, office and doctor’s handwritten notes, and records received by other physicians.
- All autopsy, laboratory, histology, cytology, pathology, radiology, CT scan, MRI, echocardiogram and cardiac catheterization reports.
- All radiology films, mammograms, myelograms, CT scans, photographs, bone scans, pathology/cytology/histology/autopsy/immunohistochemistry specimens, cardiac catheterization videos/CDS/films/reels, and echocardiogram videos.
- All pharmacy/prescription records including NDC numbers and drug information handouts/monographs.
- All billing records including all statements, itemized bills and insurance records.
Unless you initial here, no information about alcohol/substance abuse, psychiatric/psychological treatment of HIV/AIDS will be disclosed.
___ Yes, disclose HIV/AIDS information. ____ No, do NOT disclose HIV/AIDS information.
___ Yes, disclose alcohol/substance abuse information. ____ No, do NOT disclose alcohol/substance abuse
___ Yes, disclose psychiatric/psychological information. ____ No, do NOT disclose psychiatric/psychological information.
I authorize you to release the protected health information to: Calhoon and Kaminsky P.C., 2411 North Front Street, Harrisburg, PA 17110
I acknowledge the right to revoke this authorization by writing to Calhoon and Kaminsky P.C., at the above-referenced address. However, I understand that any actions already taken in reliance on this authorization cannot be reversed, and my revocation will not affect those actions. I acknowledge the potential for information disclosed pursuant to this authorization be subject to redisclosure by the recipient and no longer by protected by 45 CFR 164.508. I acknowledge the right to inspect the material to be released. I understand that the covered entity to whom this authorization is directed may not condition treatment, payment, enrollment, or eligibility benefits on whether or not I sign the authorization. Any facsimile, copy or photocopy of this authorization shall authorize you to release the records herein.
This authorization expires two years from the date below:
Signature: _____________________________________ Date: ______________________________
Relationship to the person who is the subject of the records:
Self: ________ Other: __________________________________________________________