RCUH Policies and Procedures
Research Corporation of the University of Hawaii
Employee Consent Form (D-26WC)
TO: RCUH Director of Human Resources
I, (NAME), hereby authorize my physician, hospital, clinic, insurance company or other institution or person to permit the bearer of this consent form or the Research Corporation of the University of Hawaii (RCUH), or its authorized representatives, claims adjusters, and insurance representatives to receive clarification on any medical information oral or recorded provided to by a certified/authorized medical practitioner, view, copy or be furnished verbal or written clarification and/or copies of any and all medical information, including x-rays, relating to (check appropriate box):
Processing/Administration of my Industrial Accident and related Workers’ Compensation benefits: This authorization allows release and access information and records relating to medical services and/or treatments for my injury/illness; and as applicable prior related medical history).
RCUH Job/Physical Analysis (JPA) for return to work assessment: Completion of the attached RCUH JPA Form by my physician or healthcare provider relating to the my work-related injuries/illness and/or restrictions/limitations that may affect my ability to perform my job’s essential functions pursuant to the Americans with Disabilities Act.
Processing/Administration of my RCUH Employee Benefits: This authorization allows release and access to information relating medical services/treatments for my injury/illness necessary for the processing and administration of my employee benefits as allowed by law and required by RCUH policy).
Please PRINT Contact Information of Physician:
I understand that this authorization is for a specific time period (not to exceed the time necessary to process the action checked above) and may be revoked at any time in writing. I understand this authorization is specifically for the processing of the purpose stated above. I understand that my authorized physician, hospital clinic, insurance company or other institution will not condition my treatment, payment, enrollment or eligibility for benefits on the signing of this authorization except as allowed by law. I understand that the health information released under this authorization may no longer be protected under the federal privacy regulations of the Federal Health Insurance Portability and Accountability Act (“HIPAA”). I understand that the health information released under this Authorization is also protected under the informational privacy provision of the Hawaii Constitution, Article I, Section 6 which prohibits the use and re-disclosure of this health information outside the RCUH or its authorized representatives, claims adjusters, and insurance representatives. I certify and acknowledge the RCUH requires this information for the processing/administering workers’ compensation benefits, return to work assessment or other work related matters relating to RCUH policies. I agree that a copy of this authorization bears the same authority as the original.
Signature of Employee/Claimant
The Genetic Information Nondiscrimination Act of 2008 (“GINA”) prohibits employers and other entities covered by GINA Title II from requesting or requiring genetic information of an individual or family member of the individual, except as specifically allowed by this law. To comply with this law, we are asking that you not provide any genetic information when responding to this request for medical information. “Genetic Information” as defined by GINA includes an individual’s family medical history, the results of an individual’s or family member’s genetic tests, the fact that an individual or an individual’s family member sought or received genetic services, and genetic information of a fetus carried by an individual or an individual’s family member or an embryo lawfully held by an individual or family member receiving assistive reproductive services.
Effective 12/16/1993 (Revised 09/01/2002, 10/16/2013, 09/12/2020, 02/01/2021)
RCUH Form D-26WC