Get Inspirien Medical Authorization / Release Form

Filling out the Inspirien Medical Authorization / Release Form online is a straightforward process that enables users to consent to the disclosure of their medical information for the purpose of investigating a workers’ compensation claim. This guide will help you navigate through each section of the form with ease.

Follow the steps to complete the form successfully.

1. Click the 'Get Form' button to access the medical authorization/release form and open it in your preferred online editor.
2. In the first section, provide your claim number and full name as the claimant, ensuring accuracy to avoid any processing delays.
3. Next, under the authorization section, read the provided information and instructions carefully. Confirm your understanding that any medical records may be disclosed to the Inspirien Insurance Company and its authorized agents.
4. Date your completion of the form, which is located near the signature line. This indicates when you gave your consent.
5. Sign your name on the designated line, affirming that you voluntarily waive any rights associated with patient privilege concerning the information disclosed.
6. Input your date of birth in the specified field, as it helps to verify your identity.
7. List all physicians who have treated you in the last five years, filling in their names, specialties, and contact details. If you need more space, attach a separate sheet as indicated.
8. Review the entire form to ensure all information is complete and accurate before proceeding.
9. Finally, save your changes, and choose to download, print, or share the filled form as needed.

Complete the Inspirien Medical Authorization / Release Form online today for a smooth submission process.