MCCF

Montana Contractors Compensation Fund

AUTHORIZATION TO RELEASE MEDICAL RECORDS

I give my consent to any health care provider (hospital, clinic, physician, psychologist or pharmacy), insurance company, claims administrator or employer to disclose upon request to Montana Contractor Compensation Fund or its representatives any and all information, included but not limited to claim reports, hospital or medical records including history, x-rays, other diagnostic tests, consultations, examinations, prescriptions or treatment, any and all psychological records including raw test data, relating to any illness or injury which I may have incurred or suffered. This information is being disclosed to Montana Contractor Compensation Fund or its representative to assist in determining the extent and nature of my eligibility for insurance related benefits.

This authorization applies to any prior employer, insurance carrier, social security administration, the Veterans Administration, Unemployment Insurance Division and any State or Federal public agency, all of whom may have records of my past or present claims.

I recognize that the information disclosed might contain information that is protected by Federal and/or State law, and I specifically consent to the disclosure of such information relating to the diagnosis or treatment of any mental or psychiatric conditions or alcohol and /or drug abuse.

I understand this authorization expires 30 months from the date it is signed. I have the right to revoke this authorization at any time. I understand that if I revoke this authorization, I must do so in writing and present my written revocation to Montana Contractor Compensation Fund. The authorization cannot be revoked if information has already been released as a result of the authorization.

I understand that any disclosure of information carries with it the potential for an unauthorized redisclosure and the information may not be protected by federal confidentiality rules. A photo-static copy of this authorization shall be considered as effective and valid as the original.

Date Signature

IF SIGNING IN BEHALF OF ANOTHER, INDICATE RELATIONSHIP______

NAME ______Employer ______

Claim # ______DOB: ______

SSAN: ______

Authorization for Disclosure of Health Information

Pursuant to the Montana statute 50-16-527 (4), MCA: "A signed claim for workers' compensation or occupational disease benefits authorizes disclosure to the workers' compensation insurer ... by the health care provider. The disclosure authorized by this subsection authorizes the physician or other health care provider to disclose or release only information relevant to the claimant's condition. Health care information relevant to the claimant’s condition may include past history of complaints of or the treatment of a condition that is similar to that presented in the claim, conditions for which benefits are subsequently claimed, other conditions related to the same body part, or conditions that may affect recovery. A release of information related to workers' compensation must be consistent with the provisions of this subsection. Authorization under this section is effective only as long as the claimant is claiming benefits. "

Revised 8-22-2011 PO Box 1748, Great Falls, MT, 59403

Tel. 406-453-8522 – Fax 406-453-8630