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Advisory 93-10

Medical Records Release Forms used by Carriers

A question has come up regarding the medical records release forms which insurance carriers are using.

Article 8308-4.66(d) states: "A health car facility shall, on request of either the injured employee, the employee's attorney, or the insurance carrier, furnish records pertaining to treatment or hospitalization for which compensation is being sought. All the charges for the furnishings of reports and records shall be subject to regulation by the commission; provided, however, such charges shall in no event be less than the fair and reasonable charge for the furnishings of the reports and records. A health care facility may disclose records to the insurance carrier of the affected employer pertaining to the diagnosis or treatment of an injured employee for purposes of determining the amount of payment or the entitlement to payment without the authorization of the injured employee."

The last sentence establishes the nature of records the health care facility can release to the carrier without specific authorization from the injured employee. Because this covers the majority of information which a health care facility will have available, there should be very few circumstances where a release is needed.

In those few circumstances when it is necessary to obtain the employee's authorization to release information from a health care facility or other health care provider the insurance carrier should tell the employee:

  1. which workers' compensation injury the records are requested for; and
  2. the issue which prompts the carrier to request the employee to sign the medical release.

Attached are examples of a suggested cover letter to the claimant and a copy of a suggested medical release form.

Signed this 5 th day of August, 1993.

Todd K. Brown
Executive Director

Distribution:

Austin Carrier Representatives
TWCC Staff
Public Information List

Attachments:

Suggested Cover Letter
Suggested Medical Records Release Form


Suggested Cover Letter

Date

Name of Claimant
Street Address
City, State, Zip Code

Dear (claimant):

We need your authorization to obtain medical records from ___ (provider)___. This health care provider will not release the needed medical records unless we provide them with your written authorization.

The medical records related to your present workers' compensation claim are required to make the following determination on your workers' compensation claim:

State specific determination that the carrier must make to handle the workers' compensation claim.

Example #1:

A claim for workers' compensation benefits has been made for a medical condition previously handled as non-injury related. We need to review the medical records to evaluate if we should accept responsibility for the claim.

Example #2:

Certain medical bills have been presented for medical treatment that do not appear to be related to the January 1, 1999 work related injury. We need to review the records to determine which medical charges should be covered under your workers' compensation claim.

A medical release and authorization form is attached for your signature. Please read and sign the form which authorizes ___(carrier)___ to obtain the information. Please return the signed form to our office in the envelope provided so that prompt action can occur on your claim.

If you have any questions, please contact ___ (carrier) ___ at ___ or you may call the Texas Workers' Compensation Commission helpline at 1-800-252-7031.

Sincerely,

Carrier Representative


Suggested Medical Records Release Form

Workers' Compensation Related Medical
Records Release Authorization
DATE:

TO:
(Health Care Provider)
Claimant
TWCC No.
Insurance Company Claim No

I hereby authorize you to furnish records pertaining to my workers' compensation claim as requested by the insurance carrier in the attached letter.

All associated costs from furnishing reports and records shall be subject to regulation by the Texas Workers' Compensation Commission and shall be paid by the carrier.

This authorization is in compliance with Article 8308-4.66(d) of the Texas Workers' Compensation Act. A photostatic copy of this authorization shall be considered as effective and valid as the original.

Claimant

Date



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