How to...Request a copy of your file:
Replace items in RED with your information. Make sure your request states it is a Privacy Act request. Also write Privacy Act request on the outside of your envelope. Your letter should also state whether or not you want a paper copy or a copy on CD. Remember to keep a copy for your records.
Claim Number:
Date:
Office of Workers' Compensation Programs
P.O. Box 8311
London, KY 40742-8311
RE: Your Name
Claim Number:
Date of Injury:
PRIVACY ACT REQUEST
Replace the items in Red with your information. Remember to keep a copy for your records.
I also request a copy of Physician's Name completed second opinion report be sent to me upon receipt by the Office.
Sincerely,
Your Name
Your Address
Your Phone Number
As always, replace the items in Red with your information. Write Privacy Act Request on the outside of your envelope and remember to keep a copy for your records.
Date
Office of Workers' Compensation Programs
P.O. Box 8311
Re: Your Name:
Your Claim Number:
Your Date of Injury:
RE: Your Name
Claim Number:
Date of Injury:
PRIVACY ACT REQUEST
Consider this my formal request under the Privacy Act and 5 U.S.C. 522 to obtain a complete copy of the above named case file on CD to be mailed to me at the address below.
In addition, I also request a complete accounting of disclosures on the above referenced claim.
In addition, I also request a complete accounting of disclosures on the above referenced claim.
I declare under penalty of perjury the foregoing is true and correct.
Executed this ?? day of ?? 2011 at your city, your state.
Sincerely,
Your Name
Your Address
Your Phone Number
*********************************************************
SECOND OPINION AND REFEREE DOCUMENTS:
SECOND OPINION AND REFEREE DOCUMENTS:
HOW TO...REQUEST YOUR SECOND OPINION DOCUMENTS
Replace the items in Red with your information. Remember to keep a copy for your records.
Claim Number:
Date:
Office of Workers' Compensation Programs
P.O. Box 8311
P.O. Box 8311
London, KY 40742-8311
RE: Your Name
Your Claim Number:
Your Date of Injury:
PRIVACY ACT REQUEST
I received notice of the Office directed second opinion examination scheduled for date exam is scheduled with Physician's Name. This is to notify you I will attend the scheduled appointment.
Additionally, I require the following documents to be immediately sent to me:
1. The Statement of Accepted Facts, (SOAF) the Office will be sending Physician's Name;2. The questions the Office is posing to Physician's Name; and3. Any X-Ray films or other diagnostic test results the physician performs during the examination.
I also request a copy of Physician's Name completed second opinion report be sent to me upon receipt by the Office.
Sincerely,
Your Name
Your Address
Your Phone Number
************************************************************
HOW TO...REQUEST YOUR REFEREE DOCUMENTS
HOW TO...REVOKE A MEDICAL RELEASE
HOW TO...REQUEST YOUR REFEREE DOCUMENTS
Replace the items in Red with your information. Remember to keep a copy for your records.
Claim Number:
Date:
Office of Workers' Compensation Programs
P.O. Box 8311
P.O. Box 8311
London, KY 40742-8311
RE: Your Name
Your Claim Number:
Your Date of Injury:
PRIVACY ACT REQUEST
I received notice of the Office directed referee examination scheduled for date exam is scheduled with Physician's Name. This is to notify you I will attend the scheduled appointment.
Additionally, I require the following documents to be immediately sent to me:
- The Statement of Accepted Facts, (SOAF) the Office will be sending Physician's Name;
- A copy of the Medical Conflict Statement;
- The questions the Office is posing to Physician's Name; Any X-Ray films or other diagnostic test results the physician performs during the examination; and
- A copy of the ME023
I also request a copy of Physician's Name completed referee report be sent to me upon receipt by the Office.
Sincerely,
Your Name
Your Address
Your Phone Number
************************************************************
HOW TO...REVOKE A MEDICAL RELEASE
Replace the items in red with your information. Keep a copy for your records. Send to the agency with a way to track it so you can prove it was delivered.
Insert Date:
Insert Agency Name
Insert
Agency Address
Revocation
of Consent to Release Medical Information
As of the
above date I, Insert Name hereby revoke my authorization
to disclose or release my medical information and/or records to any entity
except as allowed by law.
I revoke my authorization to disclose, obtain or release my
medical information and/or stored files regarding me in writing, verbally, via Email,
telephone and/or any other electronic means without my express written
permission.
This
revocation is all inclusive of employees, officers, managers, supervisors,
contractors, third parties and administrative personnel, as well as other agencies of the United States federal government,
legal entities, state or local agencies except as allowed by law.
This revocation effectively makes
null and void any prior permission for disclosure of medical information and will remain in effect indefinitely, unless I
personally contact you in writing to request otherwise.
Sincerely,
_____________________
Insert Your Name
Insert Your Address
********************************************
HOW TO...KEEP MEDICAL FILES FROM BEING RELEASED
Replace the items in red with your information. Give a copy to each of your providers.
PLEASE KEEP ON TOP
OF FILE
Please
consider this formal notification that I, Insert Name do
not authorize release of any medical records, report, notes, opinions,
etc…to any person, entity (including government agencies) or third party without
my express written permission in accordance with HIPAA (Health Insurance Portability and Accountability Act of 1996), the
United States legislation that provides data privacy and security provisions
for safeguarding medical information.
In addition I do not authorize release of my medical information
verbally, via Email and/or telephone to any person or entity without my express
written permission.
This notice revokes any previously signed releases and
remains in effect indefinitely.
Via my signature below, I do authorize release of
medical documentation directly to the Department of Labor, Office of Workers’
Compensation Programs, (OWCP) (P.O. Box 34090 San Antonio, TX 78265) but not any third party or contractor (including my employing agency) and only in regard to my work-related injuries under claim number Insert Claim Number.
Dated: Insert Date
________________________
Your Name
Your Address
Your Telephone Number
***********************************
HOW TO...REQUEST A COPY OF YOUR VOCATIONAL REHABILITATION FILE
As always, replace the items in Red with your information. Write Privacy Act Request on the outside of your envelope and remember to keep a copy for your records.
Claim Number:
Office of Workers' Compensation Programs
P.O. Box 8311
London, KY 40742-8311
Re: Your Name:
Your Claim Number:
Your Date of Injury:
PRIVACY ACT REQUEST
Under 5 U.S.C. 522 of the Privacy Act, consider this my formal request to obtain a complete Paper or CD copy of my Vocational Rehabilitation File to be mailed to me at the address listed below. This request includes, but is not limited to;
Any and all Medical suitability determination(s) including any and all documentation supporting medical suitability;
Any and all Vocational Rehabilitation Plan(s);
Any and all evidence and documentation supporting any Vocational Rehabilitation Plan(s);
Any and all Vocational Testing results;
Any and all documentation supporting vocational suitability;
Any and all Transferable Skills Analysis;
Any and all Labor Market Survey(s);
Any and all CA-110 regarding my vocational rehabilitation;
Any and all OWCP-3 prepared in regard to my vocational rehabilitation; and
Any and all OWCP-66 prepared in regard to my vocational rehabilitation;
I declare under penalty of perjury the above is true and correct to the best of my knowledge. Executed this Day of Month, Year at Your City and State.
Sincerely,
Your Name
Your Address
Your Phone Number
*****************************************************
HOW TO...MAKE A FREEDOM OF INFORMATION ACT, (FOIA) REQUEST
As always, replace your information with the information in Red. Write Freedom of Information Act Request on the outside of your envelope. The OWCP has 10 days to provide a written confirmation that they have received and are processing your request. Your claim number is not required for a FOIA request. Remember to keep a copy for your records. FOIA requests should be sent delivery confirmation or certified mail so you have proof of mailing.
Date:
Office of Workers' Compensation Programs
P.O. Box 8311
P.O. Box 8311
London, KY 40742-8311
FREEDOM OF INFORMATION ACT REQUEST
Pursuant to 5 U.S.C. 552 and 20 C.F.R. 10.10 and 10.11 consider this my formal request to have the following information under the Freedom of Information Act, (FOIA) regarding Dr. Physician's first and last name mailed to me at the address below:
1. Any and all complaints received by the Office in all Districts against Dr. Physician's last name; and
2. The number of times Dr. Physician's last name has performed Independent Medical Examinations, (IME) for the Office in all Districts in the last four (4) years.
Executed this Date day of Month and Year at Your City and State.
Sincerely,
Your Name
Your Address
*******************************************
