Fill and Sign the Fillable Online Laborcommission Utah Form 046 6 03doc

Form 046 Revised 6/2003 STATE OF UTAH - LABOR COMMISSION Division of Adjudication 160 East 300 South, 3rd Floor P.O. Box 146615 Salt Lake City, UT 84114-6615 (801) 530-6800 1 (800) 530-5090 Fax Number (801) 530-6804 AUTHORIZATION TO RELEASE LABOR COMMISSION RECORDS I hereby authorize and request that you release all workers’ compensation records, excluding psychiatric records in your possession. I authorize the Labor Commission to release this information to all parties, including medical and rehabilitation providers and government agencies, for the purposes of verifying, evaluating, and managing my industrial claim. By signing this form the claimant is put on notice that his/her medical records are being made available to the requesting party. This form complies with the state Government Records Access & Management Act (GRAMA). PHOTOCOPIES OF THIS AUTHORIZATION ARE AS VALID AS THE ORIGINAL. Date of Authorization for Release of Medical Records: ____________________________ _______________________________________ Signature of Claimant _______________________________________ Claimant’s Signature: Claimant’s Name (Printed) ___________________________________ ______________________________________ (Include maiden or prior names, if applicable.) Street Address _______________________________________ City/State/Zip _______________________________________ The signature is valid for one year from the Telephone Number signature date. _______________________________________ Date of Birth _______________________________________ Social Security Number _______________________________________ Date(s) of Industrial Injury/Occupational Disease THIS IS NOT A RELEASE OF CLAIM FOR DAMAGES MAIL RECORDS TO ________________________________________________ STREET ADDRESS __________________________________________________ CITY, STATE, ZIP ___________________________________________________ The Labor Commission’s charge for the search of these records is $15.00 plus $.50 per copy of any records copied.