Safety & Loss Prevention

Untitled

AUTHORIZATION FOR RELEASE

OF MEDICAL INFORMATION

I,__________________, the undersigned, do hereby consent and authorize all doctors who have treated me and hospitals in which I have been a patient, to disclose to the University of Wisconsin System, or their representatives representing the State of Wisconsin, information from my health care records including my mental health/psychiatric care records relating to my diagnosis, prognosis or treatment. I understand the specific type of information to be disclosed includes but is not limited to physician and consultation reports, clinic records, lab, x-ray, and other test results, history reports, admitting reports, discharge summaries, psychiatric and /or psychologist evaluations. Information to disclose includes treatment for any drug, alcohol abuse, physical and mental conditions.

The purpose of this disclosure is to determine benefits under a worker's compensation claim for alleged work-related _______________________.
                                                     (type of injury/illness)

This authorization for disclosure of information is effective for one year.

This consent or photostatic copy of this authorization shall be as valid and effective as the original.


__________________________________
__________________________________
Name
Date
___________________________________
Date of Birth
___________________________________
Witness Signature