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ExamWorks Clinical Solutions - HIPAA Release Form

ExamWorks Clinical Solutions - HIPAA Release Form 2026

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The document is an authorization form from ExamWorks Clinical Solutions that allows the use and disclosure of an individual's Protected Health Information (PHI) in accordance with HIPAA regulations. It outlines the individual's consent for sharing their medical records, prescription history, and other health-related information with specified entities for purposes such as evaluating Medicare Set-Asides and negotiating Conditional Payments. The form also includes acknowledgments regarding the voluntary nature of the authorization, potential risks of re-disclosure, and the individual's rights concerning their health information.

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Click ‘Get Form’ to open the ExamWorks Clinical Solutions - HIPAA Release Form in the editor.
Begin by filling in your personal information. Enter your name, Social Security Number, and address in the designated fields.
Provide your Medicare/Health Insurance Claim Number and Date of Injury. Ensure accuracy as this information is crucial for processing.
List the persons or entities authorized to provide your health information. This may include healthcare providers and insurance companies.
Specify the individuals or entities authorized to receive your information, including ExamWorks Clinical Solutions and any other relevant parties.
Detail the description of information you are authorizing for release, ensuring it covers all necessary medical records and history.
State the purpose of this authorization clearly, outlining why you are granting permission for disclosure.
Finally, review all entries for accuracy before signing and dating the form at the bottom. If applicable, include your relationship to the claimant if you are a legal representative.

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Got questions?

We have answers to the most popular questions from our customers. If you can't find an answer to your question, please contact us.

What is MCP expense?

A Medical Cost Projection (MCP) can be performed in order to project medical costs for a specific timeframe, specific recommendation (i.e. surgery), or for a specific resource (Workers Compensation fee schedule/collateral resource).

What is an example of a medical cost?

Example of Medical Expenses Payments for in-patient hospital care or residential nursing home care. Payments for weight-loss programs, smoking cessation programs, acupuncture treatments for addiction, or prescription medication.

What is a medical cost projection?

Below is the definition of Medical Cost Projection as adopted by the ICHCC CMCPS Steering Committee, September 2021: Medical Cost Projection Definition: Medical Cost Projection is the process of reviewing records to determine the future cost of medical services.

What is a medical cost projection ExamWorks?

When a case is complicated and the treatment path unclear, an ECS Medical Cost Projection (MCP) provides adjusters and defense attorneys with a chronological overview of the claimants medical treatment and professional documentation for future medical needs by identifying both Medicare-covered and non-Medicare-covered

What is the difference between a medical cost projection and a life care plan?

While medical cost projections provide estimates of medical expenses over a specific period, life care plans offer a comprehensive roadmap for addressing the ongoing needs of individuals with chronic illnesses or catastrophic injuries.

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