By my signature, I authorize the above-named physician to release medical records, or information, written or verbal, relevant to my workers' compensation claim conditions to the attorney listed above. Per ORS 656.252, OAR 436-010-0240 and OAR 436-060-0017, medical information relevant to the claim includes a past history of the complaints of, or treatment of, or a condition similar to that presented in the claim or other conditions related to the same body part. I authorize this release for the duration of my claim.
If the information to be disclosed contains any of the types or records or information listed below, additional laws relating to the use and disclosure of the information may apply. I understand and agree that this information will be disclosed if I place my initials in the applicable space next to the type of information.