Form WC-207 "Authorization and Consent to Release Medical Information" - Georgia (United States)

What Is Form WC-207?

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

Form Details:

  • Released on December 1, 2018;
  • The latest edition provided by the Georgia State Board of Workers' Compensation;
  • 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 printable version of Form WC-207 by clicking the link below or browse more documents and templates provided by the Georgia State Board of Workers' Compensation.

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Download Form WC-207 "Authorization and Consent to Release Medical Information" - Georgia (United States)

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WC-207 AUTHORIZATION AND CONSENT TO RELEASE MEDICAL INFORMATION
GEORGIA STATE BOARD OF WORKERS' COMPENSATION
AUTHORIZATION AND CONSENT TO RELEASE MEDICAL INFORMATION
Instructions:
This form shall not be filed with the Board, unless otherwise requested
TO:
RE: Employee / Patient
Print Name and Title
Last Name
First Name
M.I.
Address
SSN
Date of Injury
Birthdate
City
State
Zip Code
This document authorizes the release of only the medical information as provided below. The above-stated entity, facility or medical
practitioner is authorized to release medical information to
in accordance with applicable State and Federal laws.
The information covered by this Authorization and Consent to Release is that authorized by O.C.G.A. §34-9-207 which reads as
follows:
(a) When an employee has submitted a claim for workers' compensation benefits or is receiving payment of weekly income benefits or the
employer has paid any medical expenses, that employee shall be deemed to have waived any privilege or confidentiality concerning any
communications related to the claim or history or treatment of injury arising from the incident that the employee has had with any physician,
including, but not limited to, communications with psychiatrists or psychologist. This waiver shall apply to the employee’s medical history with
respect to any condition or complaint reasonably related to the condition for which such employee claims compensation. Notwithstanding any
other provision of law to the contrary, when requested by the employer, any physician who has examined, treated, or tested the employee or
consulted about the employee shall provide within a reasonable time and for a reasonable charge all information and records related to an
examination, treatment, testing, or consultation concerning the employee.
(b) When an employee has submitted a claim for workers' compensation benefits or is receiving payment of weekly income benefits or the
employer has paid any medical expenses, the employee, upon request, shall provide the employer with a signed release for medical records
and information related to the claim or history or treatment of injury arising from the incident, including information related to the treatment for
any mental condition or drug or alcohol abuse and to such employee’s medical history with respect to any condition or complaint reasonably
related to the condition for which such employee claims compensation. Said release shall designate the provider to whom the release is
directed. If a hearing is pending, any release shall expire on the date of the hearing.
(c)
If the employee refuses to provide a signed release for medical information as required by this Code section and, in the opinion of the
Board, the refusal was not justified under the terms of this Code section, then such employee shall not be entitled to any compensation at any
time during the continuance of such refusal or to a hearing on the issues of compensability arising from the claim.
Federal regulations (42 CFR Part 2), and the Health Insurance Portability and Accountability Act (HIPAA) of 1996 45 CFR
164.512(1) which reads as follows: “The covered entity may disclose protected health information as authorized by and to the
extent necessary to comply with laws relating to workers’ compensation or other similar programs, established by law, that
provide benefits for work-related illnesses or injury without regard to fault.” Anyone who receives information under this
authorization receives the same under all limitations set forth in Federal and State law regarding further dissemination of
such information.
This release shall expire in 180 days or upon written notice of revocation by the patient. If a hearing is pending, this release
shall remain in effect until the hearing and shall expire on the date the hearing is held.
Employee / Patient Signature
Date
IF YOU HAVE QUESTIONS PLEASE CONTACT THE STATE BOARD OF WORKERS’ COMPENSATION AT 404-656-3818 OR 1-800-533-0682 OR VISIT http://www.sbwc.georgia.gov
WILLFULLY MAKING A FALSE STATEMENT FOR THE PURPOSE OF OBTAINING OR DENYING BENEFITS IS A CRIME SUBJECT TO PENALTIES OF UP TO $10,000.00 PER VIOLATION (O.C.G.A. §34-9-18 AND §34-9-19).
AUTHORIZATION AND CONSENT
207
WC-207
REVISION 12/2018
TO RELEASE MEDICAL INFORMATION
WC-207 AUTHORIZATION AND CONSENT TO RELEASE MEDICAL INFORMATION
GEORGIA STATE BOARD OF WORKERS' COMPENSATION
AUTHORIZATION AND CONSENT TO RELEASE MEDICAL INFORMATION
Instructions:
This form shall not be filed with the Board, unless otherwise requested
TO:
RE: Employee / Patient
Print Name and Title
Last Name
First Name
M.I.
Address
SSN
Date of Injury
Birthdate
City
State
Zip Code
This document authorizes the release of only the medical information as provided below. The above-stated entity, facility or medical
practitioner is authorized to release medical information to
in accordance with applicable State and Federal laws.
The information covered by this Authorization and Consent to Release is that authorized by O.C.G.A. §34-9-207 which reads as
follows:
(a) When an employee has submitted a claim for workers' compensation benefits or is receiving payment of weekly income benefits or the
employer has paid any medical expenses, that employee shall be deemed to have waived any privilege or confidentiality concerning any
communications related to the claim or history or treatment of injury arising from the incident that the employee has had with any physician,
including, but not limited to, communications with psychiatrists or psychologist. This waiver shall apply to the employee’s medical history with
respect to any condition or complaint reasonably related to the condition for which such employee claims compensation. Notwithstanding any
other provision of law to the contrary, when requested by the employer, any physician who has examined, treated, or tested the employee or
consulted about the employee shall provide within a reasonable time and for a reasonable charge all information and records related to an
examination, treatment, testing, or consultation concerning the employee.
(b) When an employee has submitted a claim for workers' compensation benefits or is receiving payment of weekly income benefits or the
employer has paid any medical expenses, the employee, upon request, shall provide the employer with a signed release for medical records
and information related to the claim or history or treatment of injury arising from the incident, including information related to the treatment for
any mental condition or drug or alcohol abuse and to such employee’s medical history with respect to any condition or complaint reasonably
related to the condition for which such employee claims compensation. Said release shall designate the provider to whom the release is
directed. If a hearing is pending, any release shall expire on the date of the hearing.
(c)
If the employee refuses to provide a signed release for medical information as required by this Code section and, in the opinion of the
Board, the refusal was not justified under the terms of this Code section, then such employee shall not be entitled to any compensation at any
time during the continuance of such refusal or to a hearing on the issues of compensability arising from the claim.
Federal regulations (42 CFR Part 2), and the Health Insurance Portability and Accountability Act (HIPAA) of 1996 45 CFR
164.512(1) which reads as follows: “The covered entity may disclose protected health information as authorized by and to the
extent necessary to comply with laws relating to workers’ compensation or other similar programs, established by law, that
provide benefits for work-related illnesses or injury without regard to fault.” Anyone who receives information under this
authorization receives the same under all limitations set forth in Federal and State law regarding further dissemination of
such information.
This release shall expire in 180 days or upon written notice of revocation by the patient. If a hearing is pending, this release
shall remain in effect until the hearing and shall expire on the date the hearing is held.
Employee / Patient Signature
Date
IF YOU HAVE QUESTIONS PLEASE CONTACT THE STATE BOARD OF WORKERS’ COMPENSATION AT 404-656-3818 OR 1-800-533-0682 OR VISIT http://www.sbwc.georgia.gov
WILLFULLY MAKING A FALSE STATEMENT FOR THE PURPOSE OF OBTAINING OR DENYING BENEFITS IS A CRIME SUBJECT TO PENALTIES OF UP TO $10,000.00 PER VIOLATION (O.C.G.A. §34-9-18 AND §34-9-19).
AUTHORIZATION AND CONSENT
207
WC-207
REVISION 12/2018
TO RELEASE MEDICAL INFORMATION