ࡱ> 796 UbjbjSS <11, pp+:@@@@*Ea$#j-qqq@@q @@q2@@\L{~0+,?{4?2?2Lqqqqqqq qqq+qqqq?qqqqqqqqqp :  MEDICAL INFORMATION RELEASE AUTHORIZATION TO WHOM IT MAY CONCERN: IN RE: Claimant s name  FORMTEXT       SS Number  FORMTEXT       Date of Birth  FORMTEXT       For the purposes of Workers Compensation claim adjudication, you are hereby authorized and directed to furnish to the South Carolina School Boards Insurance Trust, or to its representative, adjuster, attorney or other agent, any and all information in your possession, or under your control relating to my medical or dental care, including but not limited to the following: Hospital records, x-rays, x-ray readings and reports, laboratory records, pharmacy records, and reports, all tests of any type or character, and reports thereof, statement of charges, and any and all of my records pertaining to hospitalization, history, condition, treatment, diagnosis, prognosis, etiology or expenses: Medical, dental, psychological, psychiatric, pharmacy, or chiropractic records, including patients record cards, nurses and doctors daily notes, x-rays, x-ray readings and reports, laboratory records and reports thereof, statements of charges, and any and all of my records pertaining to medical care, history, condition, treatment, diagnosis, prognosis, etiology or expense. You are further authorized and directed to furnish oral and written reports and information to the South Carolina School Boards Insurance Trust, its representative, adjuster, attorney or other agent, as requested by it on any of the foregoing matters, and to allow it to review any records relating to my workers compensation claim or to confer with it concerning my workers compensation claim. The patient understands that the information disclosed pursuant to this authorization may be subject to re-disclosure for investigative purposes and/or medical referrals, opinions, and decision-making related to my care. *The signed authorization shall not expire, and shall not be revoked so long as the claim for Workers Compensation benefits is open and/or actively pursued, unless otherwise determined by lawful agreement. *Date:_______________________ ____________________________________ PATIENT/CLAIMANT SIGNATURE XZ     & ( * N P d f h r t v x 3 }~Z[\],ٚو|tlt|g hy\hyh]5hyh5hyhz5h"jh7Vh7V>*CJU"jth7Vh7V>*CJUh7Vhz>*CJ!jh7V>*CJUmHnHu"jh7Vh7V>*CJU h7V>*CJjh7V>*CJU hzCJ h]CJhzh]'VXZ* v x 3 4 t }~\],-.rgd]gdy$ & Fa$$a$,-./UhzU h]\ hz5 hy5 h]5 NOTE: A photocopy of this authorization shall have the same effect as the original. Ugdy:PP&P:p%m/ =!"#$% tDText1tDText2tDText3^ 2 0@P`p2( 0@P`p 0@P`p 0@P`p 0@P`p 0@P`p 0@P`p8XV~_HmH nH sH tH 8`8 Normal_HmH sH tH 8@8  Heading 1$@&CJD@D  Heading 2$$@&a$ 5>*CJDA D Default Paragraph FontViV  Table Normal :V 44 la (k (No List 8B@8 Body Text$a$CJ@P@@ Body Text 2$a$5CJPK![Content_Types].xmlN0EH-J@%ǎǢ|ș$زULTB l,3;rØJB+$G]7O٭V$ !)O^rC$y@/yH*񄴽)޵߻UDb`}"qۋJחX^)I`nEp)liV[]1M<OP6r=zgbIguSebORD۫qu gZo~ٺlAplxpT0+[}`jzAV2Fi@qv֬5\|ʜ̭NleXdsjcs7f W+Ն7`g ȘJj|h(KD- dXiJ؇(x$( :;˹! I_TS 1?E??ZBΪmU/?~xY'y5g&΋/ɋ>GMGeD3Vq%'#q$8K)fw9:ĵ x}rxwr:\TZaG*y8IjbRc|XŻǿI u3KGnD1NIBs RuK>V.EL+M2#'fi ~V vl{u8zH *:(W☕ ~JTe\O*tHGHY}KNP*ݾ˦TѼ9/#A7qZ$*c?qUnwN%Oi4 =3N)cbJ uV4(Tn 7_?m-ٛ{UBwznʜ"Z xJZp; {/<P;,)''KQk5qpN8KGbe Sd̛\17 pa>SR! 3K4'+rzQ TTIIvt]Kc⫲K#v5+|D~O@%\w_nN[L9KqgVhn R!y+Un;*&/HrT >>\ t=.Tġ S; Z~!P9giCڧ!# B,;X=ۻ,I2UWV9$lk=Aj;{AP79|s*Y;̠[MCۿhf]o{oY=1kyVV5E8Vk+֜\80X4D)!!?*|fv u"xA@T_q64)kڬuV7 t '%;i9s9x,ڎ-45xd8?ǘd/Y|t &LILJ`& -Gt/PK! ѐ'theme/theme/_rels/themeManager.xml.relsM 0wooӺ&݈Э5 6?$Q ,.aic21h:qm@RN;d`o7gK(M&$R(.1r'JЊT8V"AȻHu}|$b{P8g/]QAsم(#L[PK-![Content_Types].xmlPK-!֧6 0_rels/.relsPK-!kytheme/theme/themeManager.xmlPK-!0C)theme/theme/theme1.xmlPK-! ѐ' theme/theme/_rels/themeManager.xml.relsPK] , ,U U _kq, FFF8@0(  B S  ?Text1Text2Text3`. r. .  *+,+ . . $x`*808^8`0o(()^`.pLp^p`L.@ @ ^@ `.^`.L^`L.^`.^`.PLP^P`L.$x`G          )zJ z4Q7V]yUS-R5t'%m, . @lqll(, @0@UnknownG*Ax Times New Roman5Symbol3. *Cx ArialA$BCambria Math"hHGHG@F^^!24( ( 2QHP(?R52!xx November 2, 2000Clara Cathy Nader Oh+'0X     ,8@HPNovember 2, 2000Clara Normal.dotm Cathy Nader2Microsoft Office Word@@Hm @*p@*p^՜.+,0 hp  SCSBA(  November 2, 2000 Title  !"#$%'()*+,-/0123458Root Entry Fa:Data 1TableOWordDocument<SummaryInformation(&DocumentSummaryInformation8.CompObjr  F Microsoft Word 97-2003 Document MSWordDocWord.Document.89q