Form WCB-220-C "Limited Release of Medical/Health Care Information Related to HIV/AIDS and Sexually Transmitted Diseases" - Maine

What Is Form WCB-220-C?

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-C 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-C "Limited Release of Medical/Health Care Information Related to HIV/AIDS and Sexually Transmitted Diseases" - Maine

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State of Maine Workers’ Compensation Board
Limited Release of Medical/Health Care Information
Related to HIV/AIDS and Sexually Transmitted Diseases
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’ medical records related to:
Your HIV infection status, including the results of an HIV test
The diagnosis, treatment and care of sexually transmitted diseases
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 they have related to the diagnosis, treatment and care of
the condition(s) listed above, regardless of the date of injury. 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 practitioner(s) to release
records pursuant to a later request after this release is signed through the termination date of this release.
Voluntary: I undersand 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 the medical records related to the
condition(s) indicated 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.
Potential Implications of Release: Releasing this information may have implications. Positive implications may include giving you
more complete care. Negative implications may include discrimination if the data is misused.
IMPORTANT NOTICE: By signing this form I understand that I am authorizing the release of my medical records related to
my HIV infection status and/or my medical records regarding diagnosis, treatment and care of sexually transmitted diseases.
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-C (eff. 9/1/18)
State of Maine Workers’ Compensation Board
Limited Release of Medical/Health Care Information
Related to HIV/AIDS and Sexually Transmitted Diseases
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’ medical records related to:
Your HIV infection status, including the results of an HIV test
The diagnosis, treatment and care of sexually transmitted diseases
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 they have related to the diagnosis, treatment and care of
the condition(s) listed above, regardless of the date of injury. 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 practitioner(s) to release
records pursuant to a later request after this release is signed through the termination date of this release.
Voluntary: I undersand 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 the medical records related to the
condition(s) indicated 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.
Potential Implications of Release: Releasing this information may have implications. Positive implications may include giving you
more complete care. Negative implications may include discrimination if the data is misused.
IMPORTANT NOTICE: By signing this form I understand that I am authorizing the release of my medical records related to
my HIV infection status and/or my medical records regarding diagnosis, treatment and care of sexually transmitted diseases.
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-C (eff. 9/1/18)