Form WCB-220-R "Revocation of Limited Release of Medical/Health Care Information" - Maine

What Is Form WCB-220-R?

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-R 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-R "Revocation of Limited Release of Medical/Health Care Information" - Maine

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State of Maine Workers’ Compensation Board
Revocation of Limited Release of
Medical/Health Care Information
Name:
SSN (last 4 digits): XXX-XX-
Date of Birth:
Date of Injury/Illness:
Notice to employee: This revocation must be sent to the recipient who requested access to your records. You should keep a
copy of the signed form for your records.
I ___________________________________________ am revoking the limited release of medical/health care information
(Name)
signed by me on ________________ and provided to _______________________________. This release revokes authorization
(Date)
(Employer/Insurer)
for all health care providers, unless specified below:
Only the following health care providers: ______________________________________________________________
______________________________________________________________________________________________________
I understand this revocation may result in a loss of or reduction in entitlement to workers’ compensation benefits. I also
understand this release does not apply to medical records already provided pursuant to the release.
I have read and understood this form.
I hereby revoke the release of my medical records:
Employee or Authorized Representative Signature
Date:___________
For purposes of this revocation, “authorized representative” has the same definition as set forth in 22 M.R.S.A. § 1711-C(1)(A).
Notice to employer/insurer/employee representative: Within 14 days after receipt of this form you must forward a copy to
all health care providers to whom you provided the limited release signed by the employee on the date listed above.
Notice to employee: Your health care provider may not receive your revocation immediately and will continue to release your
records until they receive a copy of this revocation. You should provide a copy of this revocation to your health care providers
as soon as possible. You should also keep a copy of this revocation for your records.
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-R (eff. 9/1/18)
State of Maine Workers’ Compensation Board
Revocation of Limited Release of
Medical/Health Care Information
Name:
SSN (last 4 digits): XXX-XX-
Date of Birth:
Date of Injury/Illness:
Notice to employee: This revocation must be sent to the recipient who requested access to your records. You should keep a
copy of the signed form for your records.
I ___________________________________________ am revoking the limited release of medical/health care information
(Name)
signed by me on ________________ and provided to _______________________________. This release revokes authorization
(Date)
(Employer/Insurer)
for all health care providers, unless specified below:
Only the following health care providers: ______________________________________________________________
______________________________________________________________________________________________________
I understand this revocation may result in a loss of or reduction in entitlement to workers’ compensation benefits. I also
understand this release does not apply to medical records already provided pursuant to the release.
I have read and understood this form.
I hereby revoke the release of my medical records:
Employee or Authorized Representative Signature
Date:___________
For purposes of this revocation, “authorized representative” has the same definition as set forth in 22 M.R.S.A. § 1711-C(1)(A).
Notice to employer/insurer/employee representative: Within 14 days after receipt of this form you must forward a copy to
all health care providers to whom you provided the limited release signed by the employee on the date listed above.
Notice to employee: Your health care provider may not receive your revocation immediately and will continue to release your
records until they receive a copy of this revocation. You should provide a copy of this revocation to your health care providers
as soon as possible. You should also keep a copy of this revocation for your records.
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-R (eff. 9/1/18)