STATE OF NEW MEXICO               WORKERS' COMPENSATION ADMINISTRATION           AUTHORIZATION TO RELEASE MEDICAL INFORMATIONRE:  WORKER:                       WCA No.:       DOB:                                    SSN:                          TO:                , HEALTH CARE PROVIDER     I authorize you or any member or employee of your office or association who hasexamined or treated me, as well as any hospital in which I have been a patient,to disclose and release complete and legible copies of any and all informationconcerning my physical or psychiatric condition, care and treatment, to myattorney Robert L. Scott, my employer,               , and/or its insurancecarrier,          ,and/or their attorneys, New Mexico Workers' CompensationAdministration's current medical cost containment contractor and/or the NewMexico Subsequent Injury Fund, or their duly authorized agents.Copies of all documentation released pursuant to this authorization shall be sentto the agency requesting this information and to me or my representative,                                     .I authorize the release of information including but not limited to:  medicalreports; clinical notes; nurses' notes; patient's history of injury; subjectiveand objective complaints; x-rays; test results; interpretation of x-rays or othertests (including a copy of the report); diagnosis and prognosis; hospital bills;bills for services you have rendered; payments received; and any other relevantand material information in your possession.  This Authorization also includes,if applicable, any hospital operational logs, emergency logs, tissues committeereports, psychiatric reports and records, physical therapy records, and alloutpatient records.  This Authorization also includes the right to request thatthe health care provider complete the Form Letter to Health Care Provider,approved by the Workers' Compensation Administration.I hereby expressly waive any laws, regulations and/or rules of ethics, whichotherwise might prevent any hospital, doctor or other person, who has treated orexamined me in a professional capacity, from releasing such records.A photostatic copy of this Authorization, which contains my signature, shall beconsidered as effective and valid as the original and shall be honored by thoseto whom it is sent or provided for a period of six months from the date below.This Release does not authorize any personal or telephonic conferences, orcorrespondence directly between any health care provider and, except for thelimited purpose of obtaining medical records, a representative of my employer,its attorney or insurance carrier, to discuss my case, and is solely for therelease of medical documentation as set forth herein.A copy of the transmittal letter to the physician shall be sent to me or myrepresentative.I revoke any and all other authorizations for release of medical recordspreviously given. Worker's Signature:                                                        DateWitness:                                                                       Date    [THIS FORM CANNOT BE ACCEPTED WITHOUT A WITNESS SIGNATURE]