Request For Release Of Information {07-6121}

Form 07-6121 (Rev 09/2018) STATE OF ALASKA DIVISION OF WORKERS' COMPENSATION 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) Pay the applicable reproduction fee. (See 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: Fir m Name (If Applicable): Requestor's Mailing Address: Requestor's Phone Number: E - Mail: Requestor222s Status: Employee Employer Insurer Claims Administrator Legal Representation Rehabilitation Specialist assigned under AS 23.30.041 Other (Please Describe): Requestor's Signature: Date: Employee's Name (Last, First, Middle Initial) : Employee's Employer at the Time of Injury: Employee's Date of Injury: Employee222s SSN (optional): Information Requested: Copy of Employee Case File , AWCB# (opt ional): Other (Describe Below or Attach Documentation) Employee's Declaration (Required if requestor is not the employee, the reemployment benefits administrator, the Workers' Compensation Appeals Commission, 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. Signed: Date: FEE SCHEDULE (Check or Money Order Only) An injured worker or the worker222s representative may obtain the first electronic copy of their case file at no charge. Subsequent requests will be charged the standard copy rates listed below. For paper copy rates, please contact the Division. Certification of Copies: $5.00 per certification Hearing/Pre - Hearing Recording Copies: $10.00 per CD Electronic File Copies: $10.00 per CD, plus processing time charged at Data Query rate Data Query: $80.00/hour, $20.00 (1/4 hour) minimum Send Completed Form to the Division of Workers' Compensation at: Workers Compensation P.O. Box 115512 Juneau, AK 99811 Tel: (907) 465-2790 Fax: (907) 465-2797 Workerscomp@alaska.gov American LegalNet, Inc. www.FormsWorkFlow.com