Department of

Human Resources

Our Goal is to ensure that we provide the best possible service to our current employees, prospective employees, retirees, and the citizens of Racine, thus making the City an employer of choice and a great place to work! We are responsible for personnel services and policies and overall employee relations for the City of Racine. We are dedicated to providing quality service to current employees, as well as to individuals seeking employment with the City.

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Authorization for Treatment & Medical Records Disclosure

Streamlining Care for Workplace Injuries

Complete the form to authorize treatment, disclose medical records, and facilitate payment for workers’ compensation claims. Your health and recovery are our priority.

City of Racine Authorization for Treatment, Disclosure of Medical Records and Payment for Worker's Compensation Injury

(EMPLOYEE- Please provide a copy of this form to every medical provider you see.)

Employee Name(Required)

Department(Required)

Email(Required)

Home Address(Required)

Address Line 2 City State / Province / Region ZIP / Postal Code

Home Phone(Required)

BUS. Phone(Required)

Date of Birth(Required)

Social Sec. #(Required)

Date of Injury:(Required)

Nature of Injury(Required)

TO: Any physician, surgeon, hospital, clinic, chiropractor, osteopath, dentist or other practitioner examining, evaluating and/or rendering treatment to the undersigned:

You are hereby authorized to release copies of any or all medical records concerning the work-related injury occurring on the above date to Cities and Villages Mutual Insurance Company (claims administrator) and/or Bowers & Associates (case management firm). Failure to release these records will delay payment of invoices. The patient will not be responsible for any charges incurred in furnishing such medical records.

IF THIS INCIDENT WILL RESULT IN TIME OFF THE JOB BEYOND THE DAY OF INJURY OR THE NEED FOR MEDICAL RESTRICTIONS, PLEASE NOTIFY THE CITY OF RACINE (SEE BELOW), SO THAT LIGHT DUTY MAY BE ARRANGED. OUR GOAL IS TO RETURN THE EMPLOYEE TO MEANINGFUL DUTY AT THE EARLIEST POSSIBLE OPPORTUNITY WHILE HONORING ALL MEDICAL RESTRICTIONS.

In the event this injury is determined not to be work-related , I understand that I am responsible for any medical charges incurred for the above injury.

INVOICES FOR SERVICES IN CONJUNCTION WITH THE ABOVE INJURY MUST BE SENT TO:

Location : Cities & Villages Mutual Insurance Company (CVMIC) 9898 W. Bluemound Road Wauwatosa, WI 53226-4319 ATTN: Greg Gilsinger

Phone : 262-784-5666

Fax : 262-784-5599

Case Management services are provided by United Healthcare. They may contact you to verify medical necessity of services and/or work releases or restrictions.

United Healthcare

Phone : 877-769-7303

Witness Signature

Date Signed

Supervisor Signature

Date Signed

Questions on this form may be directed to: Terry Parker, City of Racine Human Resources Dept. 262-636-9475

Company

This field is for validation purposes and should be left unchanged.

Download Fitness Center Reimbursement Form

About City of Racine Human Resources

Welcome to the City of Racine’s Human Resources department. Our passionate team is driven by the mission to empower our employees, enhance workplace diversity, equity, and inclusion, and recruit top talent to serve our vibrant community. Learn more about our values, objectives, and the services we provide in support of our city’s growth and development.

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