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Form 14-0043 — Authorization to Release Information Regarding Claimant Seeking Workers' Compensation Benefits

Description: 

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NAME 

Authorization to Release Information Regarding Claimant Seeking Workers' Compensation Benefits

NUMBER

14-0043

EFFECTIVE

July 1, 2023

OVERVIEW

This form is used to authorize persons to release information regarding a claimant seeking workers' compensation benefits to third parties such as the defendants in a workers' compensation case or their legal counsel.

INSTRUCTIONS

  1. Download the form by clicking on the link above. Complete the form by typing the information into the fill-able fields on the PDF or by printing the form and handwriting in print the information on the printed form.
  2. Provide the name of the claimant.
  3. Provide the claimant's date of birth.
  4. Identify the person(s) being authorized to release the claimant's information.
  5. Identify the person(s) to whom the entity is being authorized to release the claimant's information.
  6. Provide the name(s) of the defendant(s).
  7. Sign the bottom of Page 1 and provide the date of the signature. If the documents is being signed by a legal representative, provide the legal representative's full name and describe the relationship to the claimant.
  8. Type "Yes" or "No" to specifically indicate whether the claimant is authorizing release of:
    • Substance abuse information.
    • Mental health information.
    • HIV or AIDS-related information.
  9. Sign the bottom of Page 2 and provide the date of the signature. If the documents is being signed by a legal representative, provide the legal representative's full name and describe the relationship to the claimant.