LIMITED CERTIFICATE AUTHORIZING WRITTEN RELEASE OF MEDICAL/HEALTH CARE
INFORMATION, WCB-220
Filing Requirements
The employer or insurer (which can sometimes be one and the same) may
use the Limited Certificate Authorizing Written Release of Medical/Health
Care Information to request medical/healthcare records of an injured
employee. This release applies only to medical/healthcare records that
are related to the specific body part(s) or condition(s) listed on this
form.
The employer/insurer must complete all informational areas of this form
(except for “Employee Signature” and “Date”)
before asking the employee to sign, date and return the form to them.
This release in not valid without the employee’s signature (or
the signature of a person who has power of attorney for the injured employee).
Distribution
The Employment Status Report is a three-part form that is to be distributed
as follows:
Copy 1 to the Employee.
Copy 2 to the Insurer.
Copy 3 to the Employer.
The Board does not receive a copy of this report.
INSTRUCTIONS FOR COMPLETING LIMITED CERTIFICATE AUTHORIZING WRITTEN
RELEASE OF MEDICAL/HEALTH CARE INFORMATION, WCB-220
Employee: _______________________________
Enter the injured employee’s name (first name, middle initial,
last name).
Address: _________________________________
Enter the employee’s mailing address (street or P.O. Box, city,
state and zip code).
Date of Injury: ______________
Enter the date of the employee’s injury. This date should be the
same as box 42 of the Employer’s First Report of Occupational Injury
or Disease, WCB-1.
Social Security Number: _____________________
Enter the employee’s social security number.
Brief Description of Body Part(s) Injured: ___________________________________________
Enter a list of the body parts affected by the injury or illness. When
specifying a part of the body, be sure to indicate whether it is “left” or “right.” When
the injury involves fingers or toes, use the numbers one through five
to describe the body part. (One is the thumb or big toe; five is the
little finger or little toe.)
Employer: ________________________________
Enter the employer name as it was entered in box 10 of the Employer’s
First Report of Occupational Injury or Disease, WCB-1.
Address: __________________________________
Enter the address where the employer receives mail. Also enter the employer’s
phone number, including area code.
Insurer: ___________________________________
Enter the name of the employer’s workers’ compensation insurance
company. If the employer is self-insured or group self-insured, indicate
this and provide the name of the third-party administrator if there is
one.
Address: __________________________________
Enter the insurer, self-insured, or third-party administrator’s
mailing address.
Attorney (Legal Representative): __________________________________
If the employee is represented by a legal representative, enter the name
of that legal representative.
Address: __________________________________
Enter the legal representative's mailing address.
I hereby authorize the above employer, insurer, or their attorney to
obtain from any hospital, physician, osteopath, chiropractor, or other
health care provider, after payment to the provider of a reasonable fee,
any written information only which is or has been prepared in connection
with my examination or treatment regardless of date which relates to
my ____________ (i.e. body part and/or condition) only. This certificate
of authorization remains valid and must be honored for as long as I continue
to make any claim for compensation, any compensation payment scheme remains
in effect, or I receive compensation. This certificate of authorization
does NOT permit the release of any information regarding psychological,
substance abuse, sexually transmitted disease treatment, testing, or
counseling and does NOT authorize oral communication with or by any health
care provider.
______________________________ _________________
Employee Signature Date
The body part and/or condition blank must be completed. The injured
employee, or a person who holds power of attorney for the employee, must
sign the first line and enter the date of their signature on the second
line.
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