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State of Maine Workers Compensation Board
Limited Release of Medical/Health Care Information
Name:SSN (last 4 digits): XXXXXDate Birth:Date of Injury/Illness:Notice to employer/insurer/employee representative:
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What is limited release of medicalhealth?
Limited release of medicalhealth is a legal document that grants permission to release a limited amount of medical information.
Who is required to file limited release of medicalhealth?
The individual or their legal representative is required to file a limited release of medicalhealth.
How to fill out limited release of medicalhealth?
Limited release of medicalhealth can be filled out by providing personal information, specifying the information to be released, and signing the document.
What is the purpose of limited release of medicalhealth?
The purpose of limited release of medicalhealth is to allow healthcare providers to share specific medical information for designated purposes.
What information must be reported on limited release of medicalhealth?
Limited release of medicalhealth must include the individual's name, date of birth, the information to be released, and the reason for the release.
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