Fill and Sign the Mo Medical Records Form

                                                                                   MISSOURI DEPARTMENT OF LABOR AND INDUSTRIAL RELATIONS DIVISION OF WORKERS' COMPENSATION Injury Number AUTHORIZATION TO INSPECT AND/OR COPY MEDICAL RECORDS Checked By TO. Employee Employer Insurer Date of Accident Place and County of Accident Description of Injury (Must include part of body affected) You are hereby authorized to permit (NAME) in behalf of , to inspect and/or copy any and all medical (PARTY) records you have in your possession in regard to the above captioned case, which is now pending before the Division of Workers' Compensation. NOTE: The medical records which may be released according to this authorization are limited to medical treatment for the injury suffered on the date of accident listed above. ONLY records that relate to the injury listed above, as to the type of injury and the part of the body injured, may be included. Medical records from before the date of accident or medical records after the date of accident, which do not relate to this injury, may not be released pursuant to this authorization. This authorization is made in accordance with Section 287.140, RSMo., which reads as follows: ''Every hospital or other person furnishing the employee with medical aid shall permit its record to be copied by and shall furnish full information to the Commission, the employer, the employee or his dependents and any other party to any proceedings for compensation under this act, and certified copies of such records shall be admissible in evidence in any such proceedings.'' Date Signature (Division of Workers' Compensation) WC-43 (11-94) Al