Fill and Sign the Workers Compensation Claim Kit Iowa Bhhc Form

Waiver for Release of Records I, the undersigned employee, authorize the Iowa Division of Workers' Compensation to release to: __________________________________________ ___________________ . (Name of authorized recipient) the categories of confidential records that are checked below, that are in the division’s custody and that contain information that identifies me. ____ All confidential records of any nature ____ First Reports of Injury (FROI) (screen prints) filed within the past ____ years ____ Subsequent Reports of Injury (SROI) (screen prints) filed within the past ____ years ____ Evidence received in a contested case hearing ____ The transcript from a contested case hearing ____ Other (describe specific records to release) _________________________ ________________________ ___________________________________ ________________________ ___________________________________ Signed at________________ ________ this ___ day of______________, 20___. (City, State) (Print Name) Employee (Signature) To identify me and calls to verify that I signed this waiver, I provide my: Social security number: ________________________________ _____________ Date of Birth: _____________________________________________________ Address: _________________________________________________________ Telephone number: _________________ _______________________________ 14-0169 (7-05)