Medical Information & Release Form

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I understand that if I am injured while performing community service I must notify my worksite supervisor and Jamestown Community Corrections office immediately.  I also understand that my medical insurance must be used to pay for medical costs. If I do not have any medical insurance or I have costs that are not covered, I must contact the Jamestown Community Corrections office within 7 days from the date of the injury to file a claim. Otherwise I will assume full responsibility for my medical costs. I do understand that all medical information contained on this form will be released to my worksite supervisor.

I hereby authorize the release to all medical information that is related to the treatment of my injury or condition to Jamestown Community Corrections Office. I declare under penalties of perjury that I have examined this document and that it is true, correct and complete to the best of my knowledge and belief.

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