Authorization For Release Of Limited Information To Third Parties {WC190}

COLORADO DEPARTMENT OF LABOR AND EMPLOYMENT Division of Workers222 Compensation 633 17th Street, Suite 400 Denver, CO 80202-3660 Phone: (303) 318-8700 | Toll Free: (888) 39-7936 Fax: (303) 318-8710 AUTHORIZATION FOR RELEASE OF LIMITED INFORMATION TO THIRD PARTIES Claimant Social Security Number: Claimant Name: Requestor (Third Party) Name: Employer Business Name: The above referenced claimant authorizes limited access to above-mentioned requestor to all workers222 compensation files on record as stated below. This authorization shall remain in effect for ninety days from the date of claimant222s signature, unless claimant notifies the Division of Workers222 Compensation in writing before such time, that claimant is revoking said authorization. Information provided shall be limited to: Workers222 Compensation NumberDate of InjuryPart of BodyEmployer Claimant222s Signature (in presence of notary) Date Signed (to be completed by claimant) Authorization must be signed and dated by the claimant. Notarization is required. STATE OF When using an embossed seal, please shade before faxing. COUNTY OF Subscribed and sworn to before me this day of , 20 by (Print name of claimant) Place notary seal here Signature of Notary Public My commission expires: Altered forms will not be accepted. WC 190 Rev. 0/1 American LegalNet, Inc. www.FormsWorkFlow.com