Outline
The Sedgwick Medical Release form plays a crucial role in facilitating communication between healthcare providers and Sedgwick Claims Management Services, Inc. This authorization allows physicians, nurses, and hospitals to share your medical information, even if you are not present during the discussions. The form covers a wide range of health-related data, including medical history, treatment records, and psychological evaluations, specifically in relation to your workers’ compensation or disability claims. Importantly, it encompasses sensitive information, such as HIV test results and details regarding substance abuse, while also emphasizing the need to refrain from disclosing genetic information as per the Genetic Information Nondiscrimination Act. The release remains valid throughout the duration of your claims, ensuring that necessary information is available for effective claim processing. You have the right to revoke this authorization at any time, but it’s essential to understand that doing so may impact your claim’s progress. Overall, the Sedgwick Medical Release form is designed to streamline the claims process while safeguarding your privacy and rights.
Sample - Sedgwick Medical Release Form
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 Information
| Fact Name | Details |
|---|---|
| Purpose | The Sedgwick Medical Release form allows for the sharing of an individual's medical information necessary for processing claims. |
| Authorization Scope | This form covers all medical, health, psychological, and psychiatric information related to the individual’s workers’ compensation or disability claims. |
| Information Disclosure | Individuals authorize healthcare providers to share their medical information with Sedgwick and its agents. |
| Validity Period | The authorization remains valid throughout the duration of the claims and any related future claims, unless specified otherwise by law. |
| Revocation Rights | Individuals can revoke their authorization at any time by notifying Sedgwick in writing, effective upon receipt. |
| Impact of Refusal | Refusing to sign the authorization will not affect the individual's treatment or eligibility for care. |
| Re-disclosure | Sedgwick may re-disclose medical information to relevant parties without further authorization from the individual. |
| GINA Compliance | The form complies with the Genetic Information Nondiscrimination Act of 2008, prohibiting the collection of genetic information. |
| Information Types | Covered information includes health history, prescriptions, diagnostic results, and may include sensitive data like HIV status or substance abuse history. |
Detailed Guide for Filling Out Sedgwick Medical Release
After completing the Sedgwick Medical Release form, the next step involves submitting it to the appropriate parties for processing. Ensure that all information is accurate and legible to avoid delays in your claim.
- Obtain the form: Acquire the Sedgwick Medical Release form from your employer, Sedgwick's website, or your claims representative.
- Fill in your name: Write your full name as it appears on your identification documents.
- Indicate your relationship: If you are completing the form on behalf of someone else, specify your relationship to the patient.
- Enter the claim number: Provide the claim number associated with your case. This is usually found in your correspondence from Sedgwick.
- Provide the last four digits of your Social Security Number: Enter only the last four digits for privacy reasons.
- Input your date of birth: Write your date of birth in the format MM/DD/YYYY.
- Sign the form: Ensure that you sign the form where indicated. If someone else is signing on your behalf, they should also include their signature.
- Date the signature: Write the date on which you are signing the form.
Obtain Answers on Sedgwick Medical Release
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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 information is crucial for processing claims related to workers’ compensation or disability benefits. By signing this form, you grant permission for your medical history, treatment records, and other health-related information to be communicated to Sedgwick and its representatives.
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What types of information are covered by this authorization?
This authorization covers a wide range of medical and health-related information. It includes:
- Medical history and treatment records
- Psychological and psychiatric evaluations
- Diagnostic test results, such as x-rays
- Information related to pre-existing conditions
- Specific details about sensitive health issues, like HIV status or substance abuse
Essentially, any information that is relevant to your workers’ compensation or disability claims may be included.
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Who can disclose and receive my information?
Any healthcare provider who treats or examines you can disclose your information to Sedgwick. This includes:
- Your doctors and nurses
- Hospitals and clinics
- Other health facilities involved in your care
Additionally, Sedgwick can share your information with various entities, such as your employer, service providers for your claims, and the Social Security Administration, as long as it is relevant to your claim.
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How long is the authorization valid?
The Sedgwick Medical Release form remains valid for the duration of your claims and any future related claims. However, it may not exceed the term of coverage of your health insurance policy. If you need to revoke the authorization, you can do so at any time by providing written notice to Sedgwick.
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Can I revoke my authorization?
Yes, you have the right to revoke your authorization at any time. To do so, you must notify Sedgwick in writing. Keep in mind that your revocation will only take effect once Sedgwick receives your notice. Actions taken before this notice is received will not be affected by your revocation.
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What happens if I refuse to sign the authorization?
While you can refuse to sign the Sedgwick Medical Release form, doing so may impede the processing of your claim. However, your healthcare providers cannot condition your treatment or eligibility for benefits on your decision to sign or not sign this authorization.
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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. Additionally, you can inspect the disclosed information at any time. A photocopy of the authorization is considered valid and will have the same effect as the original document.
Common mistakes
Filling out the Sedgwick Medical Release form can be straightforward, but many individuals make common mistakes that can delay the processing of their claims. Awareness of these pitfalls can help ensure a smoother experience.
One frequent error is leaving out essential personal information. This includes the printed name of the patient, the claim number, and the last four digits of the Social Security Number. Omitting any of this information can lead to confusion and slow down the claims process.
Another mistake involves not signing the form. The signature is crucial as it indicates consent for the release of medical information. Without a signature, Sedgwick cannot process the claim, which can result in unnecessary delays.
Some individuals overlook the importance of specifying the relationship to the patient when a representative is signing on behalf of someone else. This detail is vital for clarity and ensures that the authorization is valid.
Failing to understand the scope of the authorization is also common. The form allows for the release of a wide range of medical information, including sensitive data. Individuals should be aware of what they are authorizing to avoid any surprises later on.
Another mistake is not checking the date signed. If the date is missing or incorrect, it can create issues with the validity of the authorization. Ensuring that the date is accurate helps maintain the integrity of the document.
Some people may provide genetic information despite clear instructions not to do so. The Genetic Information Nondiscrimination Act prohibits the inclusion of such information. Ignoring this request can lead to complications in processing the claim.
Another common error is misunderstanding the duration of the authorization. Individuals should be aware that the authorization remains valid for the duration of their claims unless stated otherwise. Not knowing this can lead to confusion about when the authorization expires.
Lastly, individuals often fail to keep a copy of the signed authorization for their records. Having a copy can be beneficial for reference and ensures that individuals have proof of what was authorized.
By avoiding these mistakes, individuals can enhance the efficiency of their claims process and minimize potential setbacks.
Documents used along the form
The Sedgwick Medical Release form is a crucial document in managing medical information for claims related to health, disability, or workers' compensation. Alongside this form, several other documents may be required to facilitate the claims process. Below is a list of commonly used forms that complement the Sedgwick Medical Release form.
- Workers' Compensation Claim Form: This form initiates a claim for benefits related to work-related injuries or illnesses. It typically requires details about the incident, medical treatment received, and the impact on the employee's ability to work.
- Disability Benefits Application: This document is used to apply for short-term or long-term disability benefits. It usually asks for personal information, medical history, and the nature of the disability affecting the individual's ability to work.
- Authorization for Release of Information: This form grants permission for healthcare providers to share specific medical information with the insurance company or claims administrator. It ensures that necessary information is disclosed to evaluate the claim effectively.
- Health Insurance Claim Form: This document is submitted to health insurance providers to request reimbursement for medical expenses. It includes information about the patient, services received, and costs incurred, allowing for proper processing of claims.
Each of these documents plays a vital role in ensuring that claims are processed efficiently and accurately. Understanding their purposes can help individuals navigate the complexities of claims management more effectively.
Similar forms
- HIPAA Release Form: Similar to the Sedgwick Medical Release form, this document allows healthcare providers to share a patient's medical information with third parties, ensuring compliance with privacy regulations.
- Patient Authorization Form: This form grants permission for healthcare providers to disclose medical records to specified individuals or organizations, much like the Sedgwick form.
- Workers’ Compensation Medical Release: This document specifically authorizes the release of medical information related to a worker's compensation claim, paralleling the Sedgwick form's focus on claims.
- Disability Benefits Authorization: Similar to the Sedgwick Medical Release, this form allows for the sharing of medical information necessary for processing disability claims.
- Release of Information Form: This document permits healthcare providers to disclose patient information to third parties, akin to the authorizations included in the Sedgwick form.
- Consent for Treatment Form: While primarily focused on consent for medical treatment, this form often includes clauses that allow for the sharing of medical information, similar to the Sedgwick form.
- Psychiatric Records Release: This document specifically pertains to the release of mental health records, much like the Sedgwick form's inclusion of psychological information.
- Substance Abuse Treatment Release: Similar to the Sedgwick form, this document authorizes the sharing of sensitive information related to substance abuse treatment.
- Genetic Information Release Form: This form allows for the disclosure of genetic information, which is a sensitive area addressed in the Sedgwick form under GINA guidelines.
- Authorization for Release of Medical Records: This document facilitates the sharing of a patient's complete medical history, echoing the broad scope of information covered in the Sedgwick Medical Release.
Dos and Don'ts
When filling out the Sedgwick Medical Release form, keep the following guidelines in mind:
- Do read the entire form carefully before signing.
- Do provide accurate and complete information to avoid delays.
- Do ensure that you sign and date the form where indicated.
- Do keep a copy of the signed form for your records.
- Don't leave any sections blank unless instructed to do so.
- Don't provide genetic information, as it is prohibited under GINA.
- Don't sign the form if you do not understand any part of it; ask for clarification.
- Don't assume that verbal communication is sufficient; always submit the written form.
Misconceptions
Understanding the Sedgwick Medical Release form can help clarify its purpose and implications. Here are six common misconceptions about this form:
- It only applies to workers' compensation claims. Many believe this form is exclusive to workers' compensation. However, it also covers claims related to short and long-term disability benefits.
- Signing the form gives Sedgwick unlimited access to my medical records. While the form allows Sedgwick to obtain necessary medical information, it is limited to what is relevant to your specific claim.
- I cannot revoke the authorization once signed. This is not true. You can revoke the authorization at any time by notifying Sedgwick in writing. However, this revocation will not affect actions taken before Sedgwick received your notice.
- All medical information is shared with my employer. The form does not automatically allow Sedgwick to disclose all your medical information to your employer. Disclosure is limited to what is necessary for your claim.
- My genetic information is required. The form specifically requests that you do not provide genetic information, as it is protected under the Genetic Information Nondiscrimination Act (GINA).
- My healthcare provider can refuse treatment if I don't sign. This is a misconception. Your healthcare providers cannot condition treatment on your decision to sign the authorization.
Clarifying these misconceptions can help individuals navigate the claims process more effectively. Always consider consulting with a professional if you have specific concerns regarding your situation.
Key takeaways
Filling out and using the Sedgwick Medical Release form is an important step in managing your claims. Here are some key takeaways to keep in mind:
- Authorization Scope: The form allows healthcare providers to share your medical information with Sedgwick, even if you are not present during the communication.
- Information Covered: This authorization includes all medical, health, psychological, and psychiatric records related to your claim.
- Exclusions: Do not provide any genetic information, as required by the Genetic Information Nondiscrimination Act (GINA).
- Disclosure Recipients: Your information may be shared with various parties, including your employer, healthcare providers, and the Social Security Administration.
- Validity Period: The authorization is valid for the duration of your claims and any future related claims.
- Revocation Rights: You can revoke your authorization at any time by notifying Sedgwick in writing.
- Impact of Refusal: Not signing the authorization may delay the processing of your claim, but healthcare providers cannot condition your treatment on your signature.
- Right to Inspect: You have the right to request a copy of the authorization and inspect the disclosed information.
- Photocopy Validity: A photocopy of the authorization is as valid as the original document.
Understanding these points can help ensure that your claims process runs smoothly and efficiently.