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The Sedgwick Medical Release Form serves a vital role in the management of health-related claims, particularly within the scope of workers' compensation and disability benefits. By signing this authorization, individuals grant permission for healthcare providers to share their identifiable medical information with Sedgwick Claims Management Services, Inc. This includes a broad array of documents, such as medical histories, treatment records, and diagnostic results, which may be necessary for processing claims. Importantly, the form also covers sensitive information regarding pre-existing conditions, mental health, and substance abuse. Understanding who may disclose and receive this information is essential, as it encompasses not only healthcare professionals but also employers and various entities involved in the claims process. The authorization remains active throughout the duration of a claim, ensuring that Sedgwick can effectively manage all aspects of the case. Individuals can revoke their consent at any time, although such a decision will not retroactively affect actions taken prior to the revocation. Knowledge of one’s rights regarding this authorization, including the right to request copies or inspect disclosed information, is crucial for maintaining control over personal health data. Thus, navigating the intricacies of the Sedgwick Medical Release Form can significantly impact the outcome of health-related claims.

Sedgwick Medical Release Example

MEDICAL AUTHORIZATION

I authorize any physicians, nurses and hospitals to communicate my individually identifiable medical or health information by any means, including written or telephonic communications or by direct interview, whether or not I am present during, or notified of, such communications, and I hereby authorize Sedgwick Claims Management Services, Inc. (Sedgwick) to initiate and conduct such communications whether or not I am present or have received notice thereof. I understand that the information about me that I authorize to be used or disclosed may be re- disclosed in accordance with the terms of this Authorization by the recipient thereof and may no longer be protected by federal or state privacy laws or regulations.

What information is covered by this authorization? This authorization applies to all medical, health, psychological, and/or psychiatric information, records and reports, including information regarding pre-existing health or medical conditions or illnesses (a) that are in existence while this authorization is valid (see Item 3) and (b) that are related to my workers’ compensation claim or, my claim for disability benefits under my employers short and long term disability plans (which may include assisting me in returning to work).

My information to be disclosed may include, but is not limited to, medical or health history, chart notes, prescriptions, diagnostic test results, x-ray reports, and records received from other health care providers. If directly related to my claimed condition or illness, this information may include information on HIV test results, HIV, AIDS, psychiatric information, or information related to drug or alcohol abuse.

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 that you not 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.

Who may disclose and receive information under this authorization?

A.Any person or facility that attends, treats, or examines me, is to make this information available to Sedgwick or any of its agents, representatives, or independent contractors; and

B.When relevant to my claim, Sedgwick may re-disclose (without my further authorization) any and all of my individually identifiable medical or health information (whether obtained pursuant to this authorization or otherwise from any person or entity) to any of the following: (a) Any person or facility that attends, treats, or examines me; (b) Any person or facility that impacts determination of my claim or that coordinates my benefits;

(c) My employer and its affiliates and their representatives, independent contractors, and service providers that may receive any such information from my employer to the extent permitted by federal or state law; (d) service providers for my long term disability or

workers’ compensation claim; or (e) The Social Security Administration or a social security or vocational rehabilitation vendor. Sedgwick may use my information obtained pursuant to this authorization in any other claim matter that Sedgwick may administer or handle related to me.

How long is this authorization valid? This authorization is valid during the duration of my claims and any future related claims, unless a different period is required under applicable federal or state law. (Release in connection with a claim for benefits for health insurance may not remain valid longer than the term of coverage of the policy; or for the duration of the claim for all other insurance claims.)

Revocation of this authorization. Unless otherwise provided by federal or state law, I understand that I may revoke this authorization at any time by notifying Sedgwick, in writing, of my revocation and that my revocation shall be effective upon Sedgwick’s receipt of my notice of revocation. I also understand that my revocation of this authorization will not have any effect on any actions taken by Sedgwick before it receives my revocation.

Processing of claims. I understand that this authorization is generally necessary for the processing of my claim. Failure to sign this authorization will likely impair or impede the processing of my claim.

Refusal to sign. I further understand my health care providers will not condition my treatment, payment, enrollment, or eligibility on my refusal to sign this authorization.

I understand that I have the right to request and receive a copy of this authorization. I understand that I have the right to inspect the disclosed information at any time. A photocopy of this authorization shall be valid and is to be accepted with the same effect as the original.

Printed Name of Patient or

 

 

 

 

Representative’s Relationship to Patient,

 

Patient’s Representative

 

 

 

 

if applicable

 

 

 

 

 

 

 

 

 

 

 

Claim Number

Last 4 Digits of Patient’s SSN

 

Patient’s Date of Birth

 

 

 

 

 

 

 

 

Signature of Patient or Patient’s Representative

 

Date Signed

 

 

 

Sedgwick 5/2017

Sedgwick Claims Management Services, Inc.
Get Sedgwick Medical Release PDF Form

Form Characteristics

Fact Name Description
Authorization Scope This form allows Sedgwick to access all medical, health, psychological, and psychiatric information relevant to the user's claims.
Validity Period The authorization remains valid for the duration of the claims and any future related claims, as allowed by applicable laws.
Disclosure Protections Once disclosed, the information may be re-disclosed and may not be protected by federal or state privacy laws.
Right to Revocation Users can revoke the authorization at any time, although revocation is effective only upon Sedgwick's receipt of the notice.

Guidelines on Utilizing Sedgwick Medical Release

After filling out the Sedgwick Medical Release form, the processed information will be used to facilitate your claims regarding health, disability, or workers’ compensation. It is crucial to complete this form accurately to ensure the timely handling of your claims.

  1. Begin by entering the Printed Name of Patient in the designated space.
  2. If applicable, indicate the Relationship to Patient for the person filling out the form.
  3. Fill in your Claim Number.
  4. Provide the Last 4 Digits of Patient’s SSN.
  5. Add the Patient’s Date of Birth in the specified format.
  6. Sign the form in the area designated as the Signature of Patient or Patient’s Representative.
  7. Finally, date the form under the Date Signed section.

What You Should Know About This Form

What is the Sedgwick Medical Release form?

The Sedgwick Medical Release form is a legal document that authorizes healthcare providers to share your medical information with Sedgwick Claims Management Services, Inc. This form ensures that Sedgwick can gather all necessary health information relevant to your workers’ compensation claim or disability benefits application.

What types of medical information does this form cover?

This authorization covers a wide range of information, including but not limited to medical history, treatment notes, prescriptions, diagnostic test results, and records from other healthcare providers. It also encompasses pre-existing conditions and, if relevant to your claim, sensitive information such as psychiatric records or substance abuse history.

Who is allowed to disclose and receive information based on this form?

Any healthcare provider involved in your treatment can disclose your medical information to Sedgwick. Conversely, Sedgwick may share your medical information with your healthcare providers, your employer, and other entities relevant to your claim, as permitted by law. This includes parties involved in coordinating your benefits or claims processing.

How long does the authorization remain valid?

The authorization remains valid as long as your claims are active and during any future related claims. However, if federal or state law specifies a different duration, that timeframe will take precedence. For health insurance claims specifically, the authorization cannot be valid beyond the term of coverage.

Can I revoke this authorization once it is signed?

Yes, you can revoke this authorization at any time by sending a written notice to Sedgwick. However, keep in mind that your revocation will only take effect once Sedgwick receives your notification. Any actions taken prior to receipt of your revocation will not be affected.

What happens if I refuse to sign the authorization?

Refusing to sign the authorization may hinder the processing of your claim. However, your healthcare provider is not permitted to condition your treatment or eligibility for benefits on your decision to sign or not sign this document.

Am I entitled to a copy of the authorization?

Yes, you have the right to request and receive a copy of the signed authorization. Additionally, you can inspect the disclosed information at any time. A photocopy of the authorization will be treated as valid as the original document.

Common mistakes

Filling out the Sedgwick Medical Release form can be a challenging task, and some common mistakes can lead to delays in processing claims. Understanding these potential pitfalls is crucial for submitting accurate information. One frequent mistake is neglecting to provide complete personal information. Ensure your name, date of birth, and claim number are correctly filled out. Missing or incorrect details can cause significant delays in the processing of your claim.

Another common error occurs when individuals forget to sign the authorization section. The form requires a signature to proceed with your claim. Without a signature, the form is considered incomplete, and no action can be taken. Review the entire form to confirm your signature is present before submission.

Many individuals also fail to specify the relationship to the patient if they are completing the form on someone else's behalf. This detail may seem minor, but it is essential for verifying who is authorized to disclose medical information. Omitting this information may lead to unnecessary back-and-forth communication.

Another mistake people make involves overlooking the section regarding genetic information. It is important to avoid including any genetic details on the form. The law prohibits the collection of such information, so your careful attention to this detail can prevent complications.

One might also overlook the definition of what information is being authorized for disclosure. Be sure you understand that this authorization includes comprehensive medical records, which may entail sensitive information. Misunderstandings here can lead to concerns about what personal data is shared.

People occasionally misjudge the duration of the authorization. It is vital to note that the authorization is valid for as long as claims are active. Not indicating this correctly can create confusion regarding when the authorization expires.

Another error involves failing to provide a method for Sedgwick to contact you if questions arise. Make sure that up-to-date contact information is included so they can reach you easily if necessary. This helps in addressing any potential issues without causing delays.

Additionally, it is crucial to understand your right to revoke the authorization. Many individuals do not recognize that they can withdraw consent at any time, which can lead to misunderstandings about ongoing medical communications.

Finally, one last area where mistakes commonly arise is in assuming that photocopies of the authorization will not be accepted. In fact, a photocopy is valid just like the original. Confirm you have retained a copy for your records for greater peace of mind.

By being aware of these nine common mistakes, you can better prepare yourself to fill out the Sedgwick Medical Release form accurately and completely. Taking the time to review your submission before handing it in can make a significant difference in the speed and efficiency of your claims process.

Documents used along the form

The Sedgwick Medical Release form is a crucial document that facilitates communication between healthcare providers and Sedgwick Claims Management Services, Inc. (Sedgwick). Along with this form, several other documents may be necessary to ensure proper processing of claims and coordination of benefits. Below is a list of commonly used forms that often accompany the Sedgwick Medical Release form.

  • Authorization for Release of Information: This document grants permission to specific individuals or organizations to access a person's medical records. It specifies which information can be shared and with whom, ensuring compliance with privacy regulations.
  • Workers’ Compensation Claim Form: This form is filed by employees to report work-related injuries or illnesses. It collects essential details about the incident, the injury sustained, and any medical treatment received, allowing for proper claim evaluation.
  • Disability Benefits Application: This application is necessary for individuals seeking short-term or long-term disability benefits. It requires detailed information regarding the individual's medical condition, the impact on their ability to work, and any supportive documentation from healthcare providers.
  • Physician’s Statement: Often required by insurance companies, this document includes a healthcare provider's assessment of the individual's medical condition and treatment recommendations. It provides critical medical insights that support the claim for benefits.
  • HIPAA Release Form: This form is designed to comply with the Health Insurance Portability and Accountability Act (HIPAA) regulations. It ensures that healthcare providers can share necessary information while protecting the individual's privacy rights.

Understanding the role of these documents in conjunction with the Sedgwick Medical Release form is vital for those navigating claims for benefits. Each form addresses specific needs and requirements in the claims process, contributing to a streamlined approach in managing an individual’s medical and insurance matters.

Similar forms

  • HIPAA Release Form: Both the Sedgwick Medical Release form and a HIPAA (Health Insurance Portability and Accountability Act) Release allow for the sharing of medical information. They ensure that healthcare providers can share your health details with authorized parties. The Sedgwick form is specifically for claims processing, while a HIPAA release generally pertains to any healthcare-related information exchange.
  • Insurance Authorization Form: Much like the Sedgwick form, an Insurance Authorization Form allows insurers to access an individual's medical records to adjudicate claims. This is crucial for the claim process, as it grants permission to review health history and any ongoing treatments.
  • Workers’ Compensation Release Form: Similar to the Sedgwick Medical Release, this document allows for the exchange of health information specifically related to workers' compensation claims. It focuses on workplace injuries and can facilitate communication between healthcare providers and claims adjusters.
  • Disability Benefits Authorization Form: This form grants permission to disclose medical information related to disability claims, just like the Sedgwick form. It assists insurers in evaluating the claim and determining eligibility for benefits based on health history.
  • Psychiatric Release Form: Used specifically for mental health records, this form shares information pertinent to psychiatric care. The Sedgwick Medical Release can also include psychological information if relevant to the claim, making them fundamentally aligned in purpose.
  • Genetic Information Release Form: While the Sedgwick form prohibits genetic information disclosure under GINA guidelines, other forms specifically address the sharing of genetic data. Both types of documents focus on the consent of individuals regarding sensitive health information.

Dos and Don'ts

When filling out the Sedgwick Medical Release form, there are key considerations to keep in mind. The following list provides guidance on what to do and what to avoid:

  • Do read the entire form carefully before signing.
  • Do provide complete and accurate information regarding your medical history.
  • Do ensure you understand the implications of authorizing communication of your medical information.
  • Do sign and date the form at the designated location to validate your authorization.
  • Do keep a copy of the signed authorization for your records.
  • Don't include any genetic information, as it is not permitted under the Genetic Information Nondiscrimination Act.
  • Don't withhold any relevant medical information that could impact your claim.
  • Don't sign the document if you do not fully comprehend what you are authorizing.
  • Don't forget to notify Sedgwick in writing if you wish to revoke the authorization in the future.
  • Don't expect treatment or benefits to be conditional upon signing this authorization.

Misconceptions

There are several misconceptions surrounding the Sedgwick Medical Release form that can lead to confusion. It's important to address these misunderstandings clearly.

  • This form gives Sedgwick access to all my medical records. The form only allows access to specific medical information that is related to your claim. It does not permit Sedgwick to disclose or access unrelated medical data.
  • I cannot revoke this authorization once I sign it. You can revoke the authorization at any time in writing. However, your revocation will only apply to future actions, not those already taken by Sedgwick before they received your notice.
  • Health care providers will refuse to treat me if I don't sign the form. Treatment, payment, or eligibility for care cannot be conditional upon your agreement to sign this authorization. Health care providers must treat you regardless of your decision.
  • My information is completely protected after I sign this form. Once you authorize disclosure, your information may be shared further and may not be protected by privacy laws, depending on who receives it.
  • Everything I disclose is only for my current claim. The authorization allows Sedgwick to use your information for any future claims related to your health or benefits, not just the current one.
  • I won't have access to the information shared. You have the right to inspect the information disclosed under this authorization at any time and can also request a copy of it.

Understanding these points is crucial. Being informed about your rights helps ensure that you can manage the information associated with your health and claims responsibly.

Key takeaways

Understanding how to fill out and use the Sedgwick Medical Release form is essential for managing your medical information effectively. Here are some key takeaways to keep in mind:

  • Authorization Scope: The form allows healthcare providers to share your medical information with Sedgwick. This includes a variety of records, from basic health history to sensitive information related to psychological evaluations or substance use.
  • Potential Risks: When you authorize the sharing of your medical information, it may be re-disclosed by Sedgwick or others without additional permission. This means it may not be protected under privacy laws once shared.
  • Genetic Information: You must not include genetic information when completing the form. This is in accordance with the Genetic Information Nondiscrimination Act of 2008.
  • Duration of Authorization: The authorization remains valid for the duration of your claims unless specified otherwise by law. This could cover any future related claims.
  • Revocation Rights: You have the right to revoke your authorization at any time by providing written notice to Sedgwick. Your revocation will only take effect after they receive it.
  • Claim Processing: Signing this authorization is typically necessary for the processing of your claims. Refusing to sign could delay or hinder the claim process, but your care providers cannot condition treatment on your decision to sign.

By following these points, you can fill out the Sedgwick Medical Release form with greater confidence and clarity. Always keep a copy of the signed form for your records.

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