Free F101-010-000 authorization to release claim information - Washington

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Claims Section Department of Labor and Industries PO Box 44291 Olympia WA 98504-4291

AUTHORIZATION TO RELEASE CLAIM INFORMATION
(to be completed by the worker
Claim No.

You or your delegate can also view your claim file documents online at the department's Claim and Account Center. For more information go to:www.Claiminfo.LNI.wa.gov. This form must be completed in full

I, authorized representative.

, designate the following individual as my
Name of authorized representative (please print))

Phone number

(
Address City State

)

ZIP +4

Please check the proper box(s). I am authorizing the release of my claim file to the authorized representative named above for review. I am authorizing the mailing of my claim file, checks & correspondence from this date forward to the authorized representative's address listed above. I am authorizing, but limit the release of information (to the authorized representative) from my claim file to the following: (for example, "all non-medical records", "the panel exam of Feb 4, 1977", etc.): please list limitations below. I am authorizing the release of information regarding sexually transmitted disease (STD), if any, as defined by state law.

This authorization will remain in effect UNTIL REVOKED IN WRITING by the claimant.
Date City Phone number Worker's address ZIP Worker's Signature

(

)
State

F101-010-000 auth to release claim info - English 04-2006