Form WCB-220-B "Limited Release of Medical/Health Care Information Related to Substance Abuse" - Maine

What Is Form WCB-220-B?

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-B 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-B "Limited Release of Medical/Health Care Information Related to Substance Abuse" - Maine

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State of Maine Workers’ Compensation Board
Limited Release of Medical/Health Care Information
Related to Substance Abuse
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. The Board’s forms may
NOT be altered. Abuses may result in penalties.
Notice to employee: The employer/insurer/employee representative contends your health care providers’ records related
to the identity, diagnosis, prognosis, or treatment of substance abuse
are relevant to whether
, regardless of the date of injury,
your claim for benefits pursuant to the Workers’ Compensation Act (Title 39-A) is compensable.
This release authorizes any and all health care providers, including Part 2 Program(s)________________________ to
(name of facility/provider)
release the records they have related to the identity, diagnosis, prognosis, or treatment of substance abuse. This release
authorizes the release of records dating from _________________ until thirty (30) 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: 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.
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-B (eff. 9/1/18)
State of Maine Workers’ Compensation Board
Limited Release of Medical/Health Care Information
Related to Substance Abuse
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. The Board’s forms may
NOT be altered. Abuses may result in penalties.
Notice to employee: The employer/insurer/employee representative contends your health care providers’ records related
to the identity, diagnosis, prognosis, or treatment of substance abuse
are relevant to whether
, regardless of the date of injury,
your claim for benefits pursuant to the Workers’ Compensation Act (Title 39-A) is compensable.
This release authorizes any and all health care providers, including Part 2 Program(s)________________________ to
(name of facility/provider)
release the records they have related to the identity, diagnosis, prognosis, or treatment of substance abuse. This release
authorizes the release of records dating from _________________ until thirty (30) 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: 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.
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-B (eff. 9/1/18)