WTC HEALTH PROGRAM NATIONWIDE PROVIDER …

1 WTC HEALTH PROGRAM NATIONWIDE PROVIDER NETWORKA uthorizAtion for release of informAtionWtC release of information 2014 Logistics HEALTH Incorporated. All rights reserved. Proprietary and 1, 2014 PATIENT NAME:WTC NuMbER:DATE Of bIRTH:PHONE:STREET ADDRESS:CITy, STATE, ZIP:i Authorize:Logistics HEALTH IncorporatedRecords Management Department328 front Street SouthLa Crosse, WI 54601 Phone: (877) 498-2911fax: (608) 793-2964To : Obtain from Disclose ToName/facility:Address: City/State/Zip: Phone:fax: i request And Authorize the release of my HEALTH informAtion noted beloW: (Please check all that apply) Entire Medical Record_____ Spirometry Report(s) Date(s)_____ Lab Report(s) Date(s)_____ X-Ray Report(s) Date(s)_____ Other: _____reAson for disClosure.

2 Patient Request Claims Administration/Payment Subpoena or Other Legal Process Insurance Application Medical Care (to allow the appropriate management of treatment, services, and/or coverage under the responder s benefits) Other: _____AuthorizAtion And ACknoWledgement:I understand that this authorization is voluntary. I understand that my HEALTH information may contain information created by other persons or entities including HEALTH care providers, and may also contain drug and alcohol, mental HEALTH , HIV/AIDS, psychotherapy, genetic, reproductive and sexually trans-mitted disease information. by my signature below, I hereby authorize Logistics HEALTH Incorporated to obtain, use and/or disclose my HEALTH information for the term of this authorization for the specific purpose listed above.

3 When information is used or disclosed by the authorized recipient, this information may be subject to re-disclosure and is no longer protected. If I am a responder applying for or receiving benefits under the WTC HEALTH PROGRAM NATIONWIDE PROVIDER network , I understand that payment, enrollment or eligibility of benefits in the WTC HEALTH PROGRAM NATIONWIDE PROVIDER network may be declined if I choose not to sign this authorization if the information requested is for the purpose of validating benefits. I also understand I have the right to receive, upon reasonable notice, a copy of the material to be disclosed as well as a copy of this authorization form. A copy or facsimile of this authorization with my signature may be used with the same effectiveness as an original.

4 I understand that this authorization is valid for one year from this date (or as set forth in applicable state law) or until _____ and may be revoked in writing by me at any time except to the extent that action has already been taken based on my Phone NumberIf Not Signed by Patient - Legal Representative s NameRelationship to PatientDescription of Representative s Authorityfor Illinois Residents Only - Witness SignatureDat