Content Overview
The Sedgwick Medical Release form serves a critical function in the claims process related to health and disability benefits. This document authorizes healthcare providers to share an individual’s medical and health information with Sedgwick Claims Management Services, Inc. The form encompasses a wide range of medical data, including health history, diagnostic test results, and treatment records, particularly those pertinent to workers' compensation or disability claims. It is essential to note that the authorization extends to any identifiable medical information, which may include sensitive details such as HIV status or psychiatric conditions. The form also outlines who may disclose and receive this information, emphasizing that various entities involved in the claims process, including employers and healthcare providers, can access the data. Furthermore, the authorization remains valid for the duration of the claims process and can be revoked at any time, although such a revocation will not affect actions taken prior to its receipt. Understanding the implications of this form is vital for individuals navigating the complexities of their health-related claims, as failure to sign may hinder the processing of their claims.
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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
My information to be disclosed may include, but is not limited to, medical or health history, chart notes, prescriptions, diagnostic test results,
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
(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 |
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Representative’s Relationship to Patient, |
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Patient’s Representative |
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if applicable |
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Claim Number |
Last 4 Digits of Patient’s SSN |
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Patient’s Date of Birth |
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Signature of Patient or Patient’s Representative |
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Date Signed |
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Sedgwick 5/2017 |
Sedgwick Claims Management Services, Inc. |
Form Specifications
| Fact Name | Details |
|---|---|
| Authorization Purpose | This form allows healthcare providers to share an individual's medical information with Sedgwick Claims Management Services for claims processing. |
| Covered Information | The authorization covers all medical, health, psychological, and psychiatric information related to the individual's workers' compensation or disability claims. |
| Disclosure Recipients | Information may be disclosed to healthcare providers, employers, and other entities involved in the claims process. |
| Validity Duration | The authorization remains valid for the duration of the claims and any related future claims unless specified otherwise by law. |
| Revocation Rights | Individuals can revoke the authorization at any time by providing written notice to Sedgwick, effective upon receipt. |
| Impact of Refusal | Refusal to sign the authorization will not affect an individual's treatment or eligibility for benefits. |
| Privacy Considerations | Disclosure may result in information being re-disclosed and may not be protected by privacy laws once shared. |
| State-Specific Laws | In states like California, the California Confidentiality of Medical Information Act governs the disclosure of medical information. |
Sedgwick Medical Release: Usage Guidelines
Filling out the Sedgwick Medical Release form is a crucial step in ensuring that your medical information is shared appropriately as part of your claim process. Once you have completed the form, it will be submitted to Sedgwick Claims Management Services, Inc. for further processing. Below are the steps to accurately fill out the form.
- Print your name: Begin by writing your full name in the designated area at the top of the form.
- Indicate your relationship: If you are completing the form on behalf of someone else, specify your relationship to the patient in the provided space.
- Claim number: Enter the claim number associated with your case. This is essential for tracking your request.
- Last four digits of SSN: Write the last four digits of the patient’s Social Security Number to ensure proper identification.
- Date of birth: Fill in the patient’s date of birth. This helps confirm the identity of the individual whose medical information is being released.
- Signature: The patient or their representative must sign the form to authorize the release of information.
- Date signed: Finally, record the date on which you signed the form. This establishes the timeline for the authorization.
Your Questions, Answered
What is the Sedgwick Medical Release form?
The Sedgwick Medical Release form is a document that allows healthcare providers to share your medical information with Sedgwick Claims Management Services, Inc. This form is essential for processing claims related to workers' compensation or disability benefits. By signing it, you authorize the release of your medical records to assist in your claim evaluation.
What types of information does the authorization cover?
This authorization covers a wide range of medical, health, psychological, and psychiatric information. It includes your medical history, treatment records, test results, and any information related to pre-existing conditions that are relevant to your workers' compensation or disability claims. Sensitive information, such as HIV status or substance abuse records, may also be disclosed if it pertains to your claim.
Who can disclose and receive my information under this authorization?
Any healthcare provider who treats you can disclose your information. Sedgwick and its representatives may also receive this information. Additionally, your employer, service providers involved in your claim, and entities like the Social Security Administration can access your medical records if necessary for your claim evaluation.
How long is the Sedgwick Medical Release form valid?
This authorization remains valid throughout the duration of your claims and any related future claims. However, specific laws may impose different validity periods, particularly for health insurance claims.
Can I revoke my authorization at any time?
Yes, you can revoke your authorization at any time by providing written notice to Sedgwick. However, your revocation will only take effect once Sedgwick receives it. Any actions taken by Sedgwick before they receive your revocation will not be affected.
What happens if I refuse to sign the authorization?
Your healthcare providers cannot condition your treatment or payment on your decision to sign the authorization. However, refusing to sign may delay or impede the processing of your claim, as this authorization is generally necessary for claim evaluation.
Am I entitled to a copy of the authorization?
Yes, you have the right to request and receive a copy of the Sedgwick Medical Release form after you sign it. This ensures you have documentation of what you authorized.
Can I inspect the disclosed information?
Absolutely. You have the right to inspect any information disclosed under this authorization at any time. This transparency helps you stay informed about your medical records and how they are being used in relation to your claim.
Is a photocopy of the authorization valid?
Yes, a photocopy of the Sedgwick Medical Release form is considered valid and will be accepted just like the original document. This means you can keep the original for your records while providing copies as needed.
Common mistakes
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Incomplete Information: Failing to provide all required personal details, such as the patient's full name, date of birth, or claim number, can delay the processing of the authorization.
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Missing Signature: Not signing the form or having an authorized representative sign can render the authorization invalid, preventing necessary communications from taking place.
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Ignoring Revocation Instructions: Not understanding that they can revoke the authorization at any time can lead to confusion about their rights regarding the disclosure of medical information.
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Providing Genetic Information: Including genetic information in the form can violate the Genetic Information Nondiscrimination Act (GINA) and may lead to complications in the processing of the claim.
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Not Specifying Timeframe: Failing to note the duration of the authorization can create uncertainty about how long the authorization is valid, which may affect future claims.
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Overlooking Privacy Concerns: Not acknowledging that the disclosed information may be re-disclosed by the recipient can lead to unintended sharing of sensitive information.
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Misunderstanding the Scope: Not recognizing that the authorization applies to a wide range of medical information can result in incomplete disclosures that hinder the claims process.
Documents used along the form
The Sedgwick Medical Release form is often accompanied by several other important documents that facilitate the claims process. Each of these forms serves a specific purpose, ensuring that all necessary information is collected and shared appropriately. Below is a list of commonly used forms alongside the Sedgwick Medical Release form.
- Workers' Compensation Claim Form: This form initiates a claim for benefits related to work-related injuries or illnesses. It collects essential details about the incident and the injured employee's information.
- Disability Benefits Application: This document is used to apply for short-term or long-term disability benefits. It requires information about the employee’s medical condition and how it affects their ability to work.
- Authorization for Release of Information: Similar to the Medical Release form, this authorization allows healthcare providers to share specific medical records with the employer or insurance company for claim processing.
- Return to Work Form: This form is completed by a healthcare provider to confirm that an employee is fit to return to work. It outlines any restrictions or accommodations needed during the transition back to work.
- Health Insurance Claim Form: This document is used to file a claim for health insurance benefits. It details the medical services received and the associated costs, allowing for reimbursement from the insurance provider.
Understanding these forms and their purposes can help streamline the claims process. Proper documentation ensures that all parties involved have the necessary information to make informed decisions regarding benefits and care.
Similar forms
The Sedgwick Medical Release form shares similarities with several other documents commonly used in healthcare and claims processing. Below is a list of eight documents that have comparable functions or purposes:
- HIPAA Release Form: This form allows healthcare providers to share a patient's medical information with designated individuals or entities, similar to the Sedgwick Medical Release, which authorizes communication of medical information for claims processing.
- Workers’ Compensation Medical Release: This document permits healthcare providers to disclose medical records related to a work-related injury, paralleling Sedgwick's focus on information pertinent to workers' compensation claims.
- Disability Claim Authorization Form: This form authorizes the release of medical records necessary for processing disability claims, much like the Sedgwick form, which facilitates the sharing of health information for disability benefits.
- Patient Information Release Form: This document allows patients to specify who can access their medical records, akin to the Sedgwick form that permits information sharing with various parties involved in claims management.
- Release of Information (ROI) Form: This form is used to authorize the release of specific health information to third parties, similar to how the Sedgwick Medical Release allows for broader communication of medical data.
- Informed Consent Form: This document ensures that patients understand and agree to the sharing of their medical information for specific purposes, much like the Sedgwick form, which informs patients about the implications of their authorization.
- Authorization for Use or Disclosure of Protected Health Information: This document is designed to authorize the use and sharing of a patient’s health information, paralleling the Sedgwick Medical Release in its focus on patient consent.
- Genetic Information Release Form: This form specifically addresses the sharing of genetic information, similar to the Sedgwick form's caution regarding genetic data under GINA, emphasizing the importance of patient privacy.
Understanding these documents can help individuals navigate the complexities of medical information sharing and claims processing. Each serves a unique purpose while ensuring that patient rights and confidentiality are respected.
Dos and Don'ts
When filling out the Sedgwick Medical Release form, it's essential to follow certain guidelines to ensure that your information is handled correctly and efficiently. Below are some dos and don'ts to consider:
- Do read the entire form carefully before signing.
- Do provide accurate and complete information regarding your medical history.
- Do ensure that you understand what information you are authorizing to be released.
- Do keep a copy of the signed authorization for your records.
- Don't include any genetic information, as it is prohibited by law.
- Don't rush through the form; take your time to avoid mistakes.
- Don't forget to sign and date the form; an unsigned form may delay processing.
- Don't assume that your healthcare provider will automatically know what to disclose; be specific.
By following these guidelines, you can help ensure that your medical release process goes smoothly and that your claims are processed without unnecessary delays.
Misconceptions
Misconceptions about the Sedgwick Medical Release form can lead to confusion regarding its purpose and implications. The following list addresses eight common misconceptions:
- The form allows Sedgwick to access any medical information at any time. The authorization is specific to the information relevant to the claim and is only valid during the duration of the claims process.
- Signing the form means I am giving up my privacy rights permanently. The authorization is limited in scope and time. You retain the right to revoke it at any time.
- My healthcare provider can refuse to treat me if I do not sign the form. Treatment cannot be conditioned on signing the authorization. Providers must offer care regardless of your decision.
- The information shared can be used for any purpose by Sedgwick. The use of your information is restricted to matters directly related to your claim and its processing.
- I will be notified each time my information is shared. The authorization allows for communication without notifying you each time, which can lead to misunderstandings about privacy.
- All medical records are automatically included in the authorization. Only records pertinent to your claim are covered. This does not include unrelated medical history.
- I cannot see the information shared about me. You have the right to inspect and request a copy of the disclosed information at any time.
- Revoking the authorization affects past actions taken by Sedgwick. Revocation only applies to future actions and does not impact any actions taken prior to receiving the revocation notice.
Key takeaways
Here are some key takeaways about filling out and using the Sedgwick Medical Release form:
- Authorization Scope: This form allows healthcare providers to share your medical information with Sedgwick. It covers a wide range of health-related details, including past and current conditions.
- Privacy Considerations: Once you authorize the release of your information, it may be shared with others and might not be protected by privacy laws anymore.
- Duration of Validity: The authorization remains valid as long as your claims are active, unless stated otherwise by law.
- Revocation Rights: You can revoke your authorization at any time by notifying Sedgwick in writing. This revocation will take effect once they receive it.
- Impact on Claims: Signing this form is generally necessary for processing your claim. Not signing could delay or complicate your claim.
- Right to Access: You have the right to request a copy of this authorization and inspect any information that has been disclosed.