Claimant Authorization To Disclose Workers Compensation Records {WC-303}

Page 1 of 2 WC-303 (12-17) AI CLAIMANT AUTHORIZATION TO DISCLOSE WORKERS222 COMPENSATION RECORDS 1. I authorize the use or disclosure of my workers' compensation records that are described below in paragraphs three and five. The last four digits of my social security number are XXX-XX-. Missouri Department of Labor and Industrial Relations 226 Division of Workers' Compensation Address: P.O. Box 58, Jefferson City. MO 65102-0058 3. The type of records and information to be used or disclosed is as follows. Please strike through all records that should not be disclosed: Any and all records concerning all injuries reported to the Division of Workers222 Compensation, including, but not limited to, reports of injury, employer's report of injury or accident, American LegalNet, Inc. www.FormsWorkFlow.com Page 2 of 2 WC-303-2 (12-17) AI A PHOTOCOPY OF THIS RELEASE IS VALID AS ORIGINAL STATE OF MISSOURI ) COUNTY OF ) Subscribed and sworn to before me this day of , 20. Notary Public My Commission Expires: (Notarial Seal) www.FormsWorkflow.com