Form 308 I PDF Details

Under the umbrella of patient rights and privacy, the Form 308 I stands as a significant document, especially within the domain of medical information sharing following HIPAA guidelines. It is designed as an Authorization to Disclose, Release, and Use Protected Health Information, serving as a cornerstone for ensuring that patient data related to health can be shared in a manner that is both legal and respects the patient's confidentiality. The form is specifically utilized within the context of workers' compensation claims, where it facilitates the release of medical records from healthcare providers to authorized entities. This sharing of information is crucial for assessing claims related to workplace injuries or occupational diseases. Key elements encapsulated in this document include the identification of the requesting party and the patient, a detailed description of the health information to be disclosed, and an acknowledgement of the potential inclusion of sensitive data such as substance abuse records. The form balances the need for information disclosure with the patient's rights, highlighting provisions for revocation except under circumstances where reliance has already been placed on the granted authorization. Additionally, it addresses the authorization's validity period and the equal authority of photostatic copies, ensuring a comprehensive approach to the sharing of protected health information in the pursuit of workers’ compensation benefits.

QuestionAnswer
Form NameForm 308 I
Form Length1 pages
Fillable?No
Fillable fields0
Avg. time to fill out15 sec
Other nameshospitalization, PHOTOSTATIC, laborcommission, summaries

Form Preview Example

FORM 308 I AUTHORIZATION TO DISCLOSE, RELEASE AND USE PROTECTED HEALTH INFORMATION

(HIPAA COMPLIANT)

PLEASE PRINT OR TYPE

Requesting Party _______________________________

Telephone Number ______________

Address _______________________________________

 

_______________________________________

Fax _______________________

TO _______________________________________________

(Medical Providers as listed on Form 307)

_______________________________________________

 

This authorization permits you to release a copy of records in your possession regarding any medical treatment and/or hospitalization of:

Name of Patient _____________________________________ Date of Birth ________________________

Social Security Number ______________________________

Date(s) of Injury/Occupational Disease _________________

I AUTHORIZE you to disclose any information and records regarding the above named individual in your possession. This includes but is not limited to, your medical findings, diagnosis, treatment, treatment summaries, prognosis, clinic notes, diagnostic reports or radiology films, physical therapy records, pharmacy records, or any other health information in your records for the past 10 years (15 years if claim is being adjudicated). I understand that based on the information released it may include information related to any substance abuse.

I UNDERSTAND that the information furnished may be used to evaluate and verify my claim for benefits for a work related injury or occupational disease. The information obtained is relevant to a workers’ compensation claim(s) and may be used by persons or organizations performing a service related to, or adjudicating the claim(s).

THIS AUTHORIZATION will expire 90 days following a resolution of the workers’ compensation claim(s) but may be revoked by signator in writing to the requesting party. Revocation of this authorization will not be valid if the requesting party has taken action in reliance upon such authorization. Please note that the information disclosed or used pursuant to this authorization may be subject to re-disclosure and would, therefore, no longer be protected under the terms of the HIPAA privacy rule.

A PHOTOSTATIC COPY of this authorization shall be deemed to have the same authority as the original.

I hereby certify that I have read the provisions in this authorization. I understand and agree to its terms, and authorize disclosure of the information described above.

________________________________________________

______________________________

Patient

Date

Please fax or mail back to the requesting party at the above fax/address.

OFFICIAL FORM 308 I

STATE OF UTAH ● LABOR COMMISSION ● DIVISION OF INDUSTRIAL ACCIDENTS

160 East 300 SouthP.O. Box 146610 Salt Lake City, UT 84114-6610 Telephone: (801) 530-6800

Fax: (801) 530-6804 Toll Free: (800) 530-5090 www.laborcommission.utah.gov

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Part # 1 of filling out gov

2. After the previous array of fields is complete, you have to include the necessary particulars in Requesting Party Address TO, Date, and Official Form I State of Utah in order to progress further.

Part number 2 for completing gov

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