AUTHORIZATION TO USE OR DISCLOSE PROTECTED INFORMATION
 - HIPAA – 

I hereby authorize use of disclosure of the named individual's health information as described below.

Patient Name		
Birth Date		
Soc. Sec.#	

RELEASE FROM:
     	
Name of Person, Company or Organization

     	
Address
     	
City, State, Zip
     		     	
Telephone Number	Fax Number

The following information is to be disclosed:  (Please Check)
Any And All Medical Records (regarding treatment with any physician that may impact your current treatment plan or for any treatment to related body parts) MRI, X-rays, Film	 Physician reports only     History & Physical Examinations
 Radiology Reports	 Discharge Summary	   Laboratory Tests	
 Consultation and Progress Notes   Insurance or Claim Records 
Employment, Payroll, Educational or Job Training   Police, Arrest, Prison or Probation Records   EDD – Disability and Unemployment records 
Any And All Records To Include Claims/ Billing Or Payment Notices For Reimbursement Of Any Medical Services Provided Under The Claimant’s Health Care Plan  Other medical records or health information here specified 

Sensitive Information: I understand that this may include information relating to (Check to Authorize Release)
Acquired Immune Deficiency Syndrome (AIDS) or infection with Human Immunodeficiency Virus (HIV) 
Behavioral Health Services, Psychiatric Care, Mental Health Treatment	
Sexually Transmitted Disease
Diagnosis/Treatment for Alcohol and/or Drug Abuse
Information for research purposes
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Services provided on (dates): ANY AND ALL DATES REGARDLESS OF TIME PERIOD SERVICES WERE RENDERED

The recipient may use the information on this form for the following purpose:
Discovery for Workers Compensation Claim (LC 4663) (Evidence Code Section 1158)(CCC Section 56)
Other 						

Re-disclosure:  I understand that the recipient may not lawfully further use or disclose the health information unless another authorization is obtained from me or unless such use or disclosure is specifically required or permitted by law. I understand that my refusal to authorize disclosure of my personal medical information will have no effect on my enrollment/eligibility for benefits, or the amount said provider pays for the health services I receive.

Prohibition of Re-disclosure:  This information has been disclosed to you for records protected by Federal Confidentiality Rules (42 CFR Part 2).  The Federal Rules prohibit you making any further disclosure of this unless disclosure is expressly permitted by the written consent of the person to whom it pertains or as otherwise permitted by 42CFR Part 2. I understand that if the person or organizations I authorize to receive and/or use my health information are not subject to the federal or state health information privacy laws, they might further disclose the health information, and the health information privacy laws may no longer protect it.

Right to Revoke:  I understand that I have the right to revoke this authorization at any time.  I understand if I revoke this authorization, I must do so in writing.  I understand that the revocation will not apply to information that has already been released based on this authorization.

Expiration:  Unless otherwise cancelled, I understand that this authorization will expire two years from the date authorization is signed.

Other Rights: I understand that authorizing the disclosure of this information is voluntary.  I understand that I may inspect or obtain a copy of the information to be used or disclosed, as provided in CFR 164.524.
 *   A PHOTOCOPY OF THIS SIGNED AUTHORIZATION WILL BE DEEMED AS EFFECTIVE AS THE ORIGINAL.  MEMBER/PATIENT HAS A RIGHT TO A COPY OF THIS AUTHORIZATION.  *

Signature of Patient or Personal Representative			Date

If signed by Representative, Relationship to Patient

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MEDICAL CLAIM HISTORY OF:

RE:	Employee:	
Employer:	Mt San Antonio Community College  District
Claim #.:	
D/Injury:	

For the purpose of having a complete medical history to provide your treating doctor, please complete the bottom of this sheet to the best of your ability.  If you have been treated at a Kaiser facility, please include your medical record number and the names of the physicians who have treated you.   Also, if you are a Medicare recipient, please include your Medicare card number or HIC number. 

During the past ten years, I have received medical treatment at the following:
(Please provide the names of Hospital/Physician, Address, Body Part and Year of Treatment.)

1.

2.

3.

4.

5.

6.

7.

8.

Have you ever had a prior workers’ compensation award or disability?    Yes or No (please circle) if yes, please explain and provide the name of the employer and the physician who made the determination of your disability.

                                                                                                                                                                    

                                                                                                                                                                    

Employee Signature:  __________________________________	Date:  __________________