Information Release Form

Information Release Form

* : required

Patient Authorization For Release of Information

NOTE: WCMC is excluded from the definition of “health plan” in the privacy rules developed pursuant to the Health Insurance Portability and Accountability Act of 1996 (HIPAA) and is not a covered entity. However, this authorization meets the core elements set forth in the HIPAA privacy rule, Sec 164.508 (c).

This is your full and sufficient authorization, pursuant to Minn. Stat. § 144.291 - 144.298, to release to:

WCMC, Inc
426 Hayward Ave North
Oakdale, MN 55128		Dave Osborne Constructions/ Nationwide Fixtures
15600 28th Ave North
Plymouth, MN 55447

their representatives or employee, all medical information (including but not limited to that which involves treatment for alcohol or drug abuse, sickle cell anemia, or mental problems) maintained while I was a patient at your facility on any date, including: Physical Exam/Laboratory Data, History, Psychological Evaluation/MMPI, Psychiatric Evaluation, psychotherapy records, Medical Progress Notes, X-ray Reports, films, radiology studies, Continuum of Care Plan, or any other type of medical record, with the following exceptions:

This information is needed for the purpose of work related claims for injuries.

This authorization specifically includes records prepared prior to the date of this authorization and records prepared after the date of this authorization during the pendency of this proceeding (including claims and potential claims). I understand that protected health information to be disclosed pursuant to this authorization may be subject to re-disclosure by the recipient and there may be a loss of protection under the Federal privacy rule or HIPPA.

I understand that I may revoke this consent in writing at any time, but that such revocation may adversely affect the course of the proceeding requiring these records and that revocation will not have any effect on the information released prior to notification of revocation. Upon the fulfillment of the above-stated purpose, this consent will automatically expire without my express revocation. A photocopy of this authorization will be treated in the same manner as an original.

Conversations by the bearer of this authorization with physicians are authorized by this release form:*

HIPAA privacy rules specifically allow covered entities to disclose protected health information as authorized and to the extent necessary to comply with law relating to workers’ compensation programs. See 45 CFR 164.512 (1).

Signature of Patient/Guardian:*
Is the patient signing?*
Signer relationship to the patient:
Reason patient is unable to sign:*
Signature Date:*02/20/2026

Authorization For Review or Release of Copies of Workers' Compensation Claims File

Employee Name:*Employee SSN#:

DOI: ANY AND ALL

I hereby authorize, Dave Osborne Constructions/ Nationwide Fixtures., and/or its agent WORKERS COMPENSATION MODIFIER CONTROLLERS, INC., to review and/or obtain copies of any or all parts of the Minnesota workers’ compensation claim file(s), for the date(s) of injury as indicated.

Signature of Patient/Guardian:*
Is the patient signing?*
Signer relationship to the patient:*
Reason patient is unable to sign:*
Signature Date:*02/20/2026

Information concerning disability may not be used to make a job decision unless state or federal law requires use of this information. Any use or distribution of this information beyond that authorized by the subject of this data unless authorized by state or federal law is prohibited. Questions concerning use of disability information may be directed to the Minnesota Department of Human Rights at (612) 296-5663 or toll-free in greater Minnesota at 1-800-652-9747.

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