Request To Erase (Redact) Medical Information From An Audio Recording {WC34}

Request to Erase (Redact) Medical Information from an Audio Recording To: Colorado Division of Workers' Compensation Attn: Customer Service Unit 633 17th Street, Suite 400 Denver, CO 80202-3626 Claimant name W.C. No: From: Address: Insurer/ Employer: Claim No: I, the injured worker, recently had an independent medical examination. I have received and listened to a copy of the audio recording of that examination. During the examination I made statements concerning a medical condition that I believe should remain private because the condition is not connected to my workers' compensation claim. I am asking that the part(s) of the recording that contain this information be erased from the recording. In order for this request to be considered I must describe, in general, the medical information I believe was private. I am not asking that any information included in the written report be erased. Since I believe this information is private I do not want to provide too much detail, but I understand I must provide enough information that a judge can find the discussion on the recording and decide whether it should remain private. The information is not relevant to my workers' compensation claim, and I am formally requesting that this information be redacted (erased) from the audio recording. The information is contained in the recording at time marker:______________________ (if available) The following is a general description of information that I request be deleted from the recording: Signature I am providing this form to the Division of Workers' Compensation along with a copy of the audio recording and a copy of the written medical report. I understand that I must send a copy of just this completed form to the doctor that examined me and to the adjuster or the insurer's attorney handling my claim. CERTIFICATE OF SERVICE: Copies of this document were placed in the U.S. Mail or hand-delivered to the following parties this ___________of _______________, ___________. List the names and addresses of all the persons copied: Insurer/ Employer: Examining Physician: By: Signature WC34 08/09 American LegalNet, Inc. www.FormsWorkFlow.com