OXFORD-Risk Management: Employee Incident Report

Medical Information Authorization Form:

Fill out forms completely and accurately and print them.
Sign all forms before sending them to Risk Management.
All unsigned forms will be returned and must be re-submitted.
Mailing and faxing instructions are listed under item #6 of Claims Processing: Instructions Page

File Number:
Today's Date:
Attention: All physicians, hospitals, clinics, dispensaries, sanitariums, pharmacists, employers and all other agencies:
You are hereby authorized and requested to furnish any representatives any and all information regarding my physical condition. This includes information regarding any injuries or disease for which I have consulted you or received your services. Also included are the nature of the physical impairment, history, contributing factors, complications, prescriptions, X-rays, copies of hospital or other records, estimates of the period or amount of disability, subjective symptoms, objective symptoms, diagnosis, prognosis and further information which may be available to you.
Name of patient:
Patient's signature:
Name of Witness:
Witness's Signature:
Please Note: A photocopy of this authorization shall be considered as effective and valid as the original.