I am making a claim for workers' compensation benefits.
The above information is true to the best of my knowledge and belief.
I authorize health care providers and other custodians of claim records to release relevant medical records to the workers' compensation insurer, self-insured employer, claim administrator, and the Oregon Department of Consumer and Business Services.
Notice: Relevant medical records include records of prior treatment for the same conditions or of injuries to the same area of the body.
A HIPAA authorization is not required (45 CFR 164.512(I)). Release of HIV/AIDS records, certain drug and alcohol treatment records, and other records protected by state and federal law requires separate authorization.
I understand I have a right to see a health care provider of my choice subject to certain restrictions under ORS 656.260 and ORS 656.325.