Authorization for Release of Medical Records and Reports

I hereby authorize the use or disclosure of my individually identifiable health information as described below. A photo copy of this authorization shall be given the same force and effect as the original.

Persons/organizations providing information include:

  • Any health care providers who have provided treatment to me at any time
  • Physicians Quality Care

Specific description of information:
All information, oral and written, including, but not limited to copies of medical records and reports concerning my past, present or future physical, mental, or emotional condition and treatment thereof. I authorize health care providers to meet with and/or discuss all aspects of my treatment including but not limited to diagnosis/prognosis, return to work, causation, or any issue regarding any aspect of my treatment and injury

Specific description of the purpose of use or disclosure:
For the administration of my claim against employer.

This authorization will expire upon the final resolution of my claim

I understand that:

  • I may revoke this authorization at any time by notifying the providing organization in writing, unless action had been taken in reliance on my authorization.
  • The information used or disclosed pursuant to this authorization may be subject to redisclosure by the recipient and may no longer be protected by federal or state law.
  • I waive any implied covenant of confidentiality with healthcare providers that I have regarding my medical treatment.
  • My healthcare provider may not condition treatment on the signing of this authorization, unless the care provided was solely for the purpose of creating health information to be provided to the contact below:
  • I have the right to refuse to sign this authorization. However, I am aware that the contact below can condition payment of my claim on the execution of this authorization and that in the event of a litigated claim, information may be released pursuant to state and federal law even if I refuse to sign.

If patient is a minor