Injured Worker Release of Info Form

Authorization for the Release of Health Information to EZ Scripts Pharmacy

This Authorization Form is designed to meet the requirements of federal privacy regulations issued by the Department of Health and Human Services at 42 CFR § 164.508.

If you need assistance completing this form or have questions, please contact us at 443.290.6337 or [email protected].

First Name*

Last Name*

Street Address*

City*

State*

Zip Code*

Phone #

Date of Birth*

I give permission to my medical providers to use and disclose the following protected health information to;
EZ Scripts Pharmacy | 24340 Sperry Dr, 2nd Floor, Westlake, OH 44145 | Fax 270.682.0975.

I hereby authorize my health care provider:

First & Last Name of Health Care Provider

(hereinafter referred to as “Entity”) to release my protected health information.

The records I authorize to release includes all service dates from the start of my injury on:

mm/dd/yyyy

PURPOSE: The protected health information is used or disclosed for workers’ compensation benefits and reimbursements for pharmacy services rendered.
EXPIRATION DATE: This authorization to disclose protected health information expires one year after this execution.
VOLUNTARY AUTHORIZATION: I may refuse to sign this authorization. Treatment, benefits, and payment cannot be conditioned on my signing of this authorization form.
INSPECTION: I may inspect or copy the protected health information to be used or disclosed under the authorization. I may inspect my protected health information without signing this form.
REVOCATION: I may revoke this authorization in writing at any time by sending a notification to EZ Scripts Pharmacy, 24340 Sperry Dr, 2nd Floor, Westlake, OH 44145.

My notice of revocation will not apply to actions taken by the requesting person/entity prior to the date they receive my written request to revoke authorization.

INFORMATION TO BE DISCLOSED
Check all that apply:

I hereby authorize my health care provider

Medical Records Treatment Records Diagnostic Records Other

Signature of Injured Worker*

Printed Full Name of Injured Worker*

Today's Date*

Injured Worker Release of Info Form

You are leaving our website