Alaska Release of Medical Information Form
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RELEASE OF MEDICAL INFORMATION
Re:

____________________________v. _________________________________
Alaska Worker's Compensation Claim No. _________________________

TO: Any doctor, chiropractor, hospital, clinic, health insurer, physical therapist, government agency, insurer,
employer or other person, entity, firm, or organization having custody of medical records or medical information
pertaining to me, the undersigned person
I, the undersigned person, give my consent and authorize you to release the following medical records and
information in your possession to ___________________________________________________________, the
defendants, or representative of the defendants, in the above Workers' Compensation Claim filed by me. I also
consent and authorize, but do not necessarily request, you to discuss the following medical records and information
pertaining to me with the defendant or the defendant's representative.
Medical records and information relating to the treatment of my
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