Form 14-0169 — Authorization for the Iowa Division of Workers' Compensation to Release Information

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Name

Authorization for the Iowa Division of Workers' Compensation to Release Information

Number

14-0169

Effective

July 2023

Overview

DWC is a State of Iowa government entity that maintains confidential information under Iowa Code section 10A.333.

DWC will not release confidential information without an Authorization to Release Information completed and signed by all persons whose confidential information is requested.

This form is not used to request information from persons other than DWC.

Instructions

To complete this form:

1. Complete Section 1 by providing all information about the employee whose confidential information DWC has.
2. Complete Section 2 by identifying all confidential information that DWC is being authorized to disclose.
3. Complete Section 3 by identifying the person(s) to whom DWC is being authorized to disclose the confidential information.
4. The person authorizing DWC to release confidential information must sign the form and provide the date of the signature.

INFORMATION REQUEST PORTAL

To access the online DWC information request portal, click here.