Form WCB-220-A "Limited Release of Medical/Health Care Information Related to Psychological Matters" - Maine

What Is Form WCB-220-A?

This is a legal form that was released by the Maine Workers' Compensation Board - a government authority operating within Maine. As of today, no separate filing guidelines for the form are provided by the issuing department.

Form Details:

  • Released on September 1, 2018;
  • The latest edition provided by the Maine Workers' Compensation Board;
  • Easy to use and ready to print;
  • Quick to customize;
  • Compatible with most PDF-viewing applications;
  • Fill out the form in our online filing application.

Download a fillable version of Form WCB-220-A by clicking the link below or browse more documents and templates provided by the Maine Workers' Compensation Board.

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Download Form WCB-220-A "Limited Release of Medical/Health Care Information Related to Psychological Matters" - Maine

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State of Maine Workers’ Compensation Board
Limited Release of Medical/Health Care Information
Related to Psychological Matters
Name:
SSN (last 4 digits): XXX-XX-
Date of Birth:
Date of Injury/Illness:
Notice to employer/insurer/employee representative:
You may only use forms adopted by the State of Maine Workers'
Compensation Board for the release of protected medical/health care information to an employer or its insurer. The Board’s forms
may NOT be altered. Abuses may result in penalties.
Notice to employee: The employer/insurer contends your health care provider’s mental health records related to:
Mental health treatment and diagnosis/diagnoses
are needed to determine whether your claim for benefits pursuant to the Workers’ Compensation Act (Title 39-A) is compensable.
This release authorizes any and all health care providers to release the records, regardless of the date of injury, they have related to the
condition(s) listed above. This release authorizes the release of records dating from ________ until twelve (12) months after the date I
sign this form. This release authorizes my health care provider(s) to release records pursuant to a later request after this release is
signed through the termination date of this release.
Voluntary: I understand I may choose not to complete this form. If I choose not to complete this form, my claim for benefits may be
denied.
Limited: I understand this form gives my health care providers permission to release only those health records related to the
condition(s) listed above. This form does NOT authorize oral communication with or by any health care provider with anyone other
than me or my representative.
Redisclosure: I understand the information provided pursuant to this release can be redisclosed for the limited purpose of determining
whether my claim for benefits pursuant to the Workers’ Compensation Act (Title 39-A) is compensable.
Revocable: I understand I may revoke this authorization at any time in writing, but doing so may result in a loss of, or reduction in,
entitlement to workers’ compensation benefits. I must revoke my authorization by completing and sending WCB Form 220-R to the
recipient listed below. Note: You may not cancel this release with respect to medical records already provided.
RIGHT TO REVIEW: You have the right to review your mental health records prior to the authorized release of the records. You
may add material to your record in order to clarify information you believe is false, inaccurate or incomplete.
Check this box if you want to review your records before they are released. By checking this box and signing below, I understand
the review will be supervised and my review of the records prior to their release may delay the consideration of my claim.
I authorize release of my medical records to: _____________________________________________________________________
(Name of Recipient)
Address of Recipient:
___________________________________________________________________________________________________________
Format Requested (circle one): Electronically (if available): _____________________________ Fax to: __________________
Mail to : __________________________________________________________________
I hereby authorize the above named recipient to obtain from my health care provider(s) subject to the terms of this release.
Employee or Authorized Representative Signature
Date:___________
For purposes of this release, “authorized representative” has the same definition as set forth in 22 M.R.S.A. § 1711-C(1)(A).
The State of Maine provides equal opportunity in employment and programs. Auxiliary aids and services are available to individuals with disabilities upon request. For
assistance with this form, contact the ADA Coordinator at the Maine Workers’ Compensation Board. Telephone: (888) 801-9087 or TTY Maine Relay 711.
WCB-220-A (eff. 9/1/18)
State of Maine Workers’ Compensation Board
Limited Release of Medical/Health Care Information
Related to Psychological Matters
Name:
SSN (last 4 digits): XXX-XX-
Date of Birth:
Date of Injury/Illness:
Notice to employer/insurer/employee representative:
You may only use forms adopted by the State of Maine Workers'
Compensation Board for the release of protected medical/health care information to an employer or its insurer. The Board’s forms
may NOT be altered. Abuses may result in penalties.
Notice to employee: The employer/insurer contends your health care provider’s mental health records related to:
Mental health treatment and diagnosis/diagnoses
are needed to determine whether your claim for benefits pursuant to the Workers’ Compensation Act (Title 39-A) is compensable.
This release authorizes any and all health care providers to release the records, regardless of the date of injury, they have related to the
condition(s) listed above. This release authorizes the release of records dating from ________ until twelve (12) months after the date I
sign this form. This release authorizes my health care provider(s) to release records pursuant to a later request after this release is
signed through the termination date of this release.
Voluntary: I understand I may choose not to complete this form. If I choose not to complete this form, my claim for benefits may be
denied.
Limited: I understand this form gives my health care providers permission to release only those health records related to the
condition(s) listed above. This form does NOT authorize oral communication with or by any health care provider with anyone other
than me or my representative.
Redisclosure: I understand the information provided pursuant to this release can be redisclosed for the limited purpose of determining
whether my claim for benefits pursuant to the Workers’ Compensation Act (Title 39-A) is compensable.
Revocable: I understand I may revoke this authorization at any time in writing, but doing so may result in a loss of, or reduction in,
entitlement to workers’ compensation benefits. I must revoke my authorization by completing and sending WCB Form 220-R to the
recipient listed below. Note: You may not cancel this release with respect to medical records already provided.
RIGHT TO REVIEW: You have the right to review your mental health records prior to the authorized release of the records. You
may add material to your record in order to clarify information you believe is false, inaccurate or incomplete.
Check this box if you want to review your records before they are released. By checking this box and signing below, I understand
the review will be supervised and my review of the records prior to their release may delay the consideration of my claim.
I authorize release of my medical records to: _____________________________________________________________________
(Name of Recipient)
Address of Recipient:
___________________________________________________________________________________________________________
Format Requested (circle one): Electronically (if available): _____________________________ Fax to: __________________
Mail to : __________________________________________________________________
I hereby authorize the above named recipient to obtain from my health care provider(s) subject to the terms of this release.
Employee or Authorized Representative Signature
Date:___________
For purposes of this release, “authorized representative” has the same definition as set forth in 22 M.R.S.A. § 1711-C(1)(A).
The State of Maine provides equal opportunity in employment and programs. Auxiliary aids and services are available to individuals with disabilities upon request. For
assistance with this form, contact the ADA Coordinator at the Maine Workers’ Compensation Board. Telephone: (888) 801-9087 or TTY Maine Relay 711.
WCB-220-A (eff. 9/1/18)