Walmartforms Sedgwicksir Com Details

Sedgwick is a company that provides disability insurance and other benefits for employees. They have created a medical release form to ensure that their clients receive the best possible care. The Sedgwick medical release form allows clients to authorize doctors to discuss their health information with Sedgwick. This form is important because it allows Sedgwick to work with healthcare providers to ensure that their clients receive the best possible care. The form can be filled out online or through paper forms available from Sedgwick. Clients are encouraged to fill out the form as soon as they are diagnosed with a medical condition that may impact their ability to work. The Sedgwick medical release form is an important document for clients of Sedgwick.

Here, you will find quite a few specifics about sedgwick medical release form PDF. It's definitely worth taking the time to learn this before you begin filling out your document.

QuestionAnswer
Form NameSedgwick Medical Release Form
Form Length2 pages
Fillable?No
Fillable fields0
Avg. time to fill out30 sec
Other namessedgwick fmla forms, sedgwick fmla paperwork, sedgwick claim forms, sedgwick leave of absence forms

Form Preview Example

AUTHORIZATION FOR RELEASE OF INFORMATION FOR SELF-INSURED DISABILITY BENEFITS (ROI)

First Name:

Street Address:

Last Name:

Claim Nbr (Mandatory):

City, State and Zip:

Employer Name:

Telephone:

Last Day Worked:

First Day Away From Work:

 

 

COMPLETE THE FOLLOWING STEPS:

STEP 1: Complete all information above. NOTE: Your Sedgwick claim number is mandatory for identification purposes.

STEP 2: Sign and return this form by FAX TO (818) 591-7664 OR by mail to Sedgwick, P.O. Box 9830, Calabasas, CA 91372-0830. Sedgwick only needs one copy of this form, so please choose one method of delivery only.

CERTIFICATION AND AUTHORIZATION FOR RELEASE OF INFORMATION

I certify all of the information above is to the best of my knowledge true, correct and complete. I hereby authorize the use or disclosure of my personal health information upon request by Sedgwick from all claim processors appointed by my employer, including but not limited to those who administer my employer’s Group Health, Short-Term Disability, Long-Term Disability, Workers’ Compensation and Employee Assistance Program (EAP).

I hereby further authorize the above persons or organizations, any physician, medical practitioner, hospital, clinic, other medical or medically related facility, pharmacy, insurer, claims administrator, and my employer(s) to disclose or furnish to Sedgwick, my employer, or any of their authorized representatives, all facts concerning my medical condition and disability (including physical, mental health, alcohol, substance abuse and HIV related information), wages or earnings, that are within their knowledge and to allow inspection of and provide copies of any medical records (including diagnosis, prognosis, prescriptions or medication, psychiatric, drug or alcohol abuse treatment).

I understand that this information will be used to determine my eligibility for benefits or compensation to which I may be entitled under any benefit plan or practice of my employer, which requires evaluation for physical or mental condition, including, but not limited to, a leave from work for medical reasons. I further authorize disclosure of my personal health information to others by Sedgwick, my employer, or any of their authorized representatives, in order to determine my eligibility for, process, evaluate and administer all claims for benefits or compensation for which I may be entitled. I also understand my healthcare provider will not condition my treatment based on this authorization. I acknowledge my right to make a copy of this authorization. I understand this authorization is valid for the duration of my claim for disability benefits or twenty-four months, whichever is earlier. A photocopy of this authorization is as valid as the original.

IMPORTANT INFORMATION ABOUT YOUR RIGHTS

I may revoke this authorization at any time before its expiration date by notifying Sedgwick in writing, but the revocation will not have any affect on any actions the party took before it received the revocation. I understand that my personal health information may be released to others in accordance with the terms of this release and I have a right to receive a copy of this information. I understand that if a recipient of the health information is not governed by federal and state confidentiality laws, the health information disclosed as a result of this authorization may be re-disclosed by the recipient and is no

Claim Nbr (Mandatory): ____________

longer protected by the Privacy Rule of the Health Insurance Portability and Accountability Act of 1996 (“HIPAA”).

*Important: The Genetic Information Nondiscrimination Act of 2008 (GINA) prohibits employers and other entities covered by GINA Title II from requesting or requiring genetic information of an individual or family member of the individual, except as specifically allowed by this law. To comply with this law, we are asking you and your health care provider not to provide any genetic information when responding to this request for medical information. "Genetic Information" as defined by GINA includes an individual's family medical history, the results of an individual's or family member's genetic tests, the fact that an individual or an individual's family member sought or received genetic services, and genetic information of a fetus carried by an individual or an individual's family member or an embryo lawfully held by an individual or family member receiving assistive reproductive services.

___________

________

_________________

Employee’s Signature

 

Date of Birth

 

Date Signed

Name of Personal Representative who has Authority to Sign on Behalf of the Employee

Signature of Personal Representative who has Authority to Sign on Behalf of the Employee

NOTE: ALL PAGES OF THIS RELEASE OF INFORMATION MUST BE RETURNED WITH YOUR SIGNATURE.

WEB_ ROI_0000

FORM 39 3/23/11