Workers' Compensation Medical Records Request Form

INSTRUCTIONS: PLEASE COMPLETE FORM AND CLICK "SUBMIT" BUTTON BELOW (can also fax copy to 615-936-6077)

Today's Date

IN ACCORDANCE WITH TENNESSEE STATE LAW, WE CANNOT RELEASE MEDICAL RECORDS FOR WORKERS' COMPENSATION INJURIES WITHOUT A SIGNED RELEASE OF INFORMATION FORM. PLEASE FAX THE RELEASE FORM TO 615-936-6077 IF YOU HAVE NOT ALREADY DONE SO.

YOUR NAME:

YOUR COMPANY:

Telephone:

Fax:

E-mail address:

PATIENT'S NAME:

Date of Injury:

Date of Birth:

Social Security Number:

Medical Record Number:

PHYSICIAN SEEN:

Date of Service:

PHYSICIAN SEEN:

Date of Service:

Follow-up Appointment Date:

Time:

BY LAW, MEDICAL RECORDS AND NOTES CANNOT BE SENT VIA E-MAIL. YOUR REQUESTED INFORMATION WILL BE SENT VIA FAX OR U.S. MAIL AS YOU REQUEST.

Please send me requested information via:

FaxU.S. Mail

Mail medical records to (Optional):

Address

City

State

Zip

THIS INFORMATION IS BEING TRANSMITTED OVER A SECURE, ENCRYPTED LINE.

This e-mail may contain confidential and privileged information for the sole use of the intended recipient(s). Any review, use, distribution, or disclosure by others is strictly prohibited.

Workers' Compensation Medical Records Request Form

VANDERBILT MEDICAL CENTER CORPORATE HEALTH SERVICES