"Authorization for Release of Confidential Information" - Rhode Island

Authorization for Release of Confidential Information is a legal document that was released by the Rhode Island Department of Administration - a government authority operating within Rhode Island.

Form Details:

  • Released on May 1, 2015;
  • The latest edition currently provided by the Rhode Island Department of Administration;
  • Ready to use and print;
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  • Compatible with most PDF-viewing applications;
  • Fill out the form in our online filing application.

Download a printable version of the form by clicking the link below or browse more documents and templates provided by the Rhode Island Department of Administration.

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Download "Authorization for Release of Confidential Information" - Rhode Island

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State of Rhode Island and Providence Plantations
Department of Administration
Division of State Employees Workers' Compensation
One Capitol Hill
Providence, Rhode Island 02908-5866
Authorization for Release of Confidential Information
Claimant’s Name:
Date:
Birth Date:
Social Security Number:
I authorize physicians, clinicians, counselors, hospitals, counseling agencies, clinics, etc.
and all attendants thereto to furnish full and complete medical, diagnostic, treatment,
Clinical, counseling, service reports and billing records, and other information hereby
requested by the DOA/ State Employees Workers’ Compensation.
The information being sought is to be used in evaluation of a pending workers’
compensation claim. Failure to authorize release of this information may cause a delay in
processing that claim.
This authorization is valid until revoked by written request to State Employees Workers’
Compensation.
The State Employees Workers’ Compensation will not release any information supplied
except in accordance with law.
I agree that a photocopy of this authorization shall be valid as the original.
Signed this ________day of ___________________, 20___.
Patient/Claimant:
Witness:
__________________________________
__________________________________
Print
__________________________________
Signature
TDD#: 222-2187
Rev:5/2015
State of Rhode Island and Providence Plantations
Department of Administration
Division of State Employees Workers' Compensation
One Capitol Hill
Providence, Rhode Island 02908-5866
Authorization for Release of Confidential Information
Claimant’s Name:
Date:
Birth Date:
Social Security Number:
I authorize physicians, clinicians, counselors, hospitals, counseling agencies, clinics, etc.
and all attendants thereto to furnish full and complete medical, diagnostic, treatment,
Clinical, counseling, service reports and billing records, and other information hereby
requested by the DOA/ State Employees Workers’ Compensation.
The information being sought is to be used in evaluation of a pending workers’
compensation claim. Failure to authorize release of this information may cause a delay in
processing that claim.
This authorization is valid until revoked by written request to State Employees Workers’
Compensation.
The State Employees Workers’ Compensation will not release any information supplied
except in accordance with law.
I agree that a photocopy of this authorization shall be valid as the original.
Signed this ________day of ___________________, 20___.
Patient/Claimant:
Witness:
__________________________________
__________________________________
Print
__________________________________
Signature
TDD#: 222-2187
Rev:5/2015