STATE OF CONNECTICUT
WORKERS’ COMPENSATION COMMISSION
AUTHORIZATION FOR RELEASE OF MEDICAL RECORDS
BY A HOSPITAL/PROVIDER
FOR THE PURPOSE OF ADMINISTERING A
CONNECTICUT WORKERS’ COMPENSATION CLAIM FOR BENEFITS
PATIENT NAME: ______________________________________ DATE OF BIRTH: ___________________
(PLEASE PRINT NAME) (REQUIRED)
BODY PART(S): ____________________________________________________________________________
I, the undersigned, authorize: __________________________________________________________________
(HOSPITAL/PROVIDER)
to disclose, in writing, protected health information [PHI] to:
____________________________________________________________________________________________
(PERSON OR ENTITY TO WHOM INFORMATION IS TO BE DISCLOSED)
and its attorneys and/or representatives. The PHI to be disclosed is relevant medical records and reports relating to
my medical treatment/consultation/examination and/or diagnostic procedures performed at the above-named
medical facility and which pertain to an injury/occupational disease for which I am claiming benefits under the
Connecticut Workers’ Compensation Act. I understand the information disclosed based on this authorization may
include mental health treatment records and information regarding HIV/AIDS status, treatment or testing.
INFORMATION RELATING TO TREATMENT FOR ALCOHOL AND DRUG ABUSE WILL NOT BE
RELEASED WITHOUT MY SPECIFIC CONSENT in accordance with state and federal law.
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I understand
I have the right to inspect or copy the PHI to be disclosed as permitted under federal HIPAA law and state law.
I UNDERSTAND THAT I HAVE THE RIGHT TO REFUSE TO SIGN THIS AUTHORIZATION.
I UNDERSTAND THAT I HAVE THE RIGHT TO REVOKE THIS AUTHORIZATION. In order to revoke
this authorization I may, at any time, send written notification to the above-named HOSPITAL/PROVIDER.
I understand that my revocation of this authorization is ineffective to the extent that the above-named
HOSPITAL/PROVIDER has relied on this authorization to disclose PHI relating to me.
I UNDERSTAND THAT PHI DISCLOSED PURSUANT TO THIS AUTHORIZATION MAY BE
REDISCLOSED BY THE PERSON OR ENTITY I HAVE IDENTIFIED ABOVE AND MAY NO
LONGER BE PROTECTED FROM DISCLOSURE TO OTHERS BY FEDERAL OR STATE LAW.
I understand that the above-named HOSPITAL/PROVIDER may not condition my treatment on whether I provide
authorization for the requested use or disclosure.
I UNDERSTAND THAT I HAVE THE RIGHT TO DETERMINE A DATE OR EVENT AT WHICH TIME
THIS AUTHORIZATION EXPIRES. I am identifying the expiration date of this authorization to be
COMPLETION OF WORKERS’ COMPENSATION LITIGATION AS EVIDENCED BY A STIPULATION OR
FINDING AND AWARD/DISMISSAL, OR IN THE EVENT OF APPELLATE REVIEW, A FINAL
DETERMINATION BY THE HIGHEST APPELLATE AUTHORITY TO WHOM AN APPEAL IS MADE.
I further understand that federal HIPAA law does not require me to provide an authorization in this form as the
purpose of this authorization relates to a Workers’ Compensation matter. However, I understand that as a practical
matter, my authorization in this form may facilitate the processing and administration of my claim for Workers’
Compensation benefits.
My signature below indicates that I have read and understand this Authorization and its terms.
_________________________________________ ________________________________________
Signature of Patient Date
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Any consent to release information pertaining to treatment for drug and alcohol abuse must conform to the requirements of state law and the
federal regulations, e.g., Part 2 of Title 42 of the Code of Federal Regulations.
Effective June 1, 2004/Revised November 23, 2009
