Dear Members:

We want privacy, but the UPRR is in for piracy.

The attached Word document is the form managers bring to employees

Who are injured on the job. In the guise of a HIPAA release, managers are misleading injured employees to sign this release. It is nothing more than the Carrier's attempt to have the employee release all of his personal medical information to the claims agent and who knows who else.

Please inform everyone about this treacherous act and not to sign this

form.  If a manager forces or infers discipline if not signed, IMMEDIATELY

CALL YOUR UNION REPRESENTATIVE.

Thank You

John

UNION PACIFIC RAILROAD COMPANY AUTHORIZATION TO OBTAIN INFORMATION (Word Doc.)

(Below is a copy of the Form.)

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UNION PACIFIC RAILROAD COMPANY

AUTHORIZATION TO USE OR DISCLOSE

HEALTH INFORMATION

(HIPAA COMPLIANT)

            I HEREBY AUTHORIZE any doctor, hospital, rehabilitation counselor, or any other provider of medical or rehabilitation services to me, to release the information specified below to UNION PACIFIC RAILROAD COMPANY (“Union Pacific”).

            I UNDERSTAND that the information authorized includes matters with respect to loss or injuries sustained on the date shown above.

            I AUTHORIZE the release of my medical records, including any information available as to my diagnosis, treatment prognosis with respect to any physical or mental condition and/or the treatment thereof; as well as my medical history, or non-medical information to Union Pacific or to its representatives.

            I UNDERSTAND that the information furnished will be used to evaluate and verify my claim for personal injuries.  The information obtained will not be released to anyone by Union Pacific, except to persons or organizations performing a service related to the above claim.  Any information released by Union Pacific may no longer be subject the federal privacy protections and is subject to redisclosure by the recipient.

            I UNDERSTAND that I may revoke this authorization by notifying the Union Pacific Claims Representative in writing.

            I AGREE that a photocopy of this Authorization shall be as valid as the original.  This Authorization shall expire 90 days following settlement, if any, of my above noted personal injury claim.

SIGNED AT                           _______, this                day of                          , 200___.

                                (City, State)                                  (date)                                        (month)                           (year)

WITNESSES:                                                                                      (Claimant Signature)