Authorization To Release Information-Verification Or Information {LIBC-552}

DEPARTMENT OF LABOR & INDUSTRY BUREAU OF WORKERS222 COMPENSATION AUTHORIZATION TO RELEASE INFORMATION002 Claimant Name (Please type or legibly print claimant name) Date of Birth Social Security Number The injured employee (or dependent, if the employee is deceased) must complete and sign the following authorization, which the Uninsured Employers Guaranty Fund may use to collect records relating to medical treatment that the injured or deceased employee received and to collect wage information from the injured or deceased employee222s current or previous employer(s). To Whom It May Concern: By signing below, I hereby request and authorize you to furnish to the Pennsylvania Uninsured Employers Guaranty Fund, or its representative(s), any and all information you have concerning the above-named employee with respect to any illness or injury, medical history, consultation, treatment, including x-rays, as well as copies of all hospital or medical records, military records, or other government records. I further request and authorize employers to furnish complete information concerning wages, commissions, employee222s dependent authorized to request the release of such records, and that I am pursuing a claim for hereby further agrees, upon request by the UEGF, to physically sign and authorize any subsequently provided Signature Date Workers222 Compensation Employer Information Claims Information Services Hearing Impaired Auxiliary aids and services are available upon request to individuals with disabilities.002 Equal Opportunity Employer/Program002 American LegalNet, Inc. www.FormsWorkFlow.com