EMPLOYER SERVICES-AUTHORIZATION FOR DISCLOSURE OF PROTECTED HEALTH INFORMATION (PHI) HIPAA RELEASE

I, the Concentra TelemedTM user, authorize Concentra to use and disclose my protected health information (PHI).

PURPOSE OF DISCLOSURE

Occupational injury/illness

CONFIRMATION OF WHO MAY RECEIVE COPIES OF YOUR RECORDS

The employer who authorized this visit

IN CONNECTION WITH THIS AUTHORIZATION:

  • I am aware that copies of records for services rendered through the use of Concentra Telemed and subsequent related visits containing PHI which may include the results of tests or evaluations, including diagnosis, and medical history, transcription notes, and tests and evaluations performed that my employer, prospective employer or third party entity has ordered or requires.
  • I give Concentra authorization to release to my employer, insurance company, and/or their representatives any medical information which is obtained as part of the treatment for this work related injury/illness, or employment-related examination.
  • I understand that if the person or entity that receives the above information is not a health care provider or health plan covered by federal privacy regulations, the information described above may be re-disclosed by such person or entity and will likely no longer be protected by the federal privacy regulations.
  • I understand that I may revoke this authorization at any time, except to the extent that action has already been taken by Concentra, by providing a written request to [email protected].
  • I understand that Concentra may not deny treatment if I do not complete this authorization form, but may deny services when the services are only to create PHI for disclosure to a third party.
  • I have a right to not sign this authorization or to limit the information I authorize to be disclosed to the minimum necessary, however, refusal to sign this authorization or to limit disclosure of my PHI may violate a condition of employment or prospective employment.
  • I may revoke this authorization at any time, but I must do so by submitting a written notice to the Concentra center where I received services. However, if I am here for a work-related visit that is subject Workers’ Compensation, under some state laws I am not allowed to revoke this authorization.
  • I have a right to receive a copy of this authorization.

For HIPAA questions related to this form, please contact the Privacy Office at 1-800-819-5571.

By typing “Yes” in the Concentra Telemed platform, I am electronically signing this authorization and intend to be legally bound thereby.