Fill and Sign the Form 205 Revised 122006 State of Utah Labor Commission

Form 205 Revised 12/2006STATE OF UTAH - LABOR COMMISSION Division of Industrial Accidents160 East 300 South, 3rd Floor P.O. Box 146610 Salt Lake City, UT 84114-6610 (801) 530-6800 1(800) 530-5090 Fax Number (801) 530-6804 AUTHORIZATION TO RELEASE INDUSTRIAL ACCIDENT DIVISION RECORDS I hereby authorize and request that you release all records pertaining to my industrial injury(s) or illness(s) in your possession. I authorize the Industrial Accidents Division to release this information to the requesting party, for the purposes of verifying, evaluating, and managing my industrial claim. By signing this form the claimant is put on notice that his/her records, including medical records, are being made available to the requesting party. This form complies with the state Government Records Access & Management Act (GRAMA). Records Requested: Date of Injury Listed Only  Records for All Injuries (give specific time frame) _________________ PHOTOCOPIES OF THIS AUTHORIZATION ARE AS VALID AS THE ORIGINAL. Subscribed and sworn to before me this day of , 20 _______________________________ Signature of Claimant _______________________________ NOTARY PUBLIC Claimant’s Name (Printed) Residing at: ___________________ _______________________________ Street Address ____________________________ ___________________________ ____ City/State/Zip ____________________________ ___________________________ ____ My Commission Expires: Telephone Number _______________________________ Date of Birth_______________________________ Social Security Number_______________________________ Date of Injury/Occupational Disease THIS IS NOT A RELEASE OF CLAIM FOR DAMAGES Requester’s Name ___________________________ Signature_________________ (print) Mail Records To _________________________________ Date________________ Street Address ______________________________________________________ City/ State/ Zip ______________________________________________________ Telephone Number _______________________________ The Industrial Accidents charge for the search of these records is $15.00 plus $.50 per copy of any records copied.