Free Request for Release of Information - Alaska

File Size: 158.2 kB
Pages: 2
Date: December 31, 2008
File Format: PDF
State: Alaska
Category: Workers Compensation
Author: Mike Monagle
Word Count: 573 Words, 3,647 Characters
Page Size: Letter (8 1/2" x 11")

Download Request for Release of Information ( 158.2 kB)

Preview Request for Release of Information
Pursuant to Alaska Statute 23.30.107, medical or rehabilitation records maintained by the Alaska Workers' Compensation Division, or held by the Alaska Workers' Compensation Board, including employee personal information, are not public records subject to public inspection under AS 40.25. To obtain records from the Division or the Board, you are required to 1) Provide the information requested below. An incomplete form will delay processing your request. 2) Provide photographic identification. a. For an in-person request, show your photo ID to Division staff. b. For mail-in, fax, or email requests, attach a copy of your ID to this form. 3) Pay the applicable reproduction fee. (See reverse side for fee schedule) A request for information by a person other than the employee may require the employee's written consent. See below.

Requestor's Printed Name: Firm Name (if applicable): Requestor's Mailing Address: Requestor's Phone Number: Fax Number: Email: Requestor's Status: Employee Employer Insurer Claims Administrator Legal Representative Rehabilitation Specialist assigned under AS 23.30.041 Other (describe below) Employee's Name: (First, Last, Middle Initial) Employee's Employer at the time of injury: Employee's Date of Injury: Information Requested: Copy of Employee Case File Other (describe below or attach documentation) Requestor's Signature: Employee's Declaration
(Required if requestor is not the employee, the reemployment benefits administrator, the Workers' Compensation Appeals Commission, a physician providing medical services under AS 23.30.095(k) or 23.30.110(g), a party to a claim filed by the employee, or a government agency)

I hereby authorize release of the aforementioned information. This consent is limited to the work related injuries referenced above on an ongoing basis. I understand that an additional consent to release information will not be necessary unless or until I revoke this authorization in writing.



Mail Completed Form To the Division of Workers' Compensation at one of these offices: ANCHORAGE P.O. Box 107019 Anchorage, AK 99510-7019 (907) 269-4980 (phone) (907) 269-4975 (fax) FAIRBANKS 675 Seventh Ave., Station K Fairbanks, AK 99701-4593 (907) 451-2889 (phone) (907) 451-2928 (fax) JUNEAU P.O. Box 115512 Juneau, AK 99811-5512 (907) 465-2790 (phone) (907) 465-2797 (fax)

Form 07-6121 (Revised 01/2/09)

After information has been provided in response to receipt of a Request For Release of Information, a copy of this form must be placed in the employee's case file. All requests for database information must be forwarded to the Juneau office.

Date Request Received: Injured Worker's Name (First, Last, Middle Initial): AWCB Case Number(s): Requestor's Photo ID Type: Driver's License Identification Number: Signature of staff who checked Photo ID: File Copied By: Mailed on by (date) (staff name) Bill Prepared By: Bill Mailed on by (date) (staff name) FEE SCHEDULE

Military ID


Other (describe below)

Picked up on (date)

by (name)

(Check or Money Order Only) An injured worker may obtain the first copy (if under 100 pages) or first 100 pages of their case file at no charge. Subsequent requests will be charged the standard copy rates listed below.

Paper Copies: $.35 per page Microfilm Copies: $.75 per page Microfiche Copies: $50.00 per fiche Certification of Copies: $5.00 per certification Hearing Recording Copies: $10.00 per recording Data Query: $80.00/hr, $20.00 (ΒΌ hr) minimum

Form 07-6121 (Revised 01/2/09)