Fill and Sign the Information for Medical Providers Nc Industrial Commission

FORM 25C 1/2004 P AGE 1 OF 1 F ORM 25C N ORTH CAROLINA INDUSTRIAL COMMISSION M AIN TELEPHONE : (919) 807-2500 H ELPLINE : (800) 688-8349 W EBSITE : HTTP ://WWW .IC .NC .GOV / North Carolina Industrial Commission IC File # A UTHORIZATION FOR REHABILITATION PROFESSIONAL Emp. Code # TO OBTAIN MEDICAL RECORDS OF CURRENT TREATMENT Carrier Code # Carrie r File # The Use Of This Form Is Required Under The Provisions of The Workers' Compensation Act Employer FEIN ( ) - Employee’s Name Employer's Name Telephone Number Address Employer’s Address City State Zip City State Zip Insurance Carrier ( ) - ( ) - Home Telephone Work Telephone Carrier’s Address City State Zip - - M F / / ( ) - ( ) - Social Security Number Sex Date of Birth Carrier's Telephone Number Fax Number I, , the employee-claimant, hereby authorize the (Please Print) release of all my medical record s of treatment resulting from a work-related injury/occupational disease that occurred/was contracted on to the Rehabilitation (Please Print) Professional assigned to me. That Rehabilitation Professional is: Name: Address: Telephone: ( ) - / / Employee’s Signature Date N OTE : THE REFUSAL OF THE CLAIMANT TO SIGN THIS FORM UPON THE REQUEST OF THE REHABILITATION P ROFESSIONAL MAY BE DEEMED BY THE INDUSTRIAL COMMISSION TO BE NONCOMPLIANCE WITH REHABILITATION AND MAY RESULT IN THE SUSPENSION OF BENEFITS . PLEASE MAIL THIS COMPLETED FORM TO THE REHABILITATION PROFESSIONAL NAMED ABOVE .