Employee Authorization To Release Confidential WC Records {WC-1151}

LWC-WC-1151 Page 1 of 2 Revised 8/1/17 EMPLOYEE AUTHORIZATION FOR OWCA TO RELEASE CONFIDENTIAL WORKERS222 COMPENSATION RECORDS EMPLOYEE : Please be aware that you DO NOT have to release all of your confidential information and you have a right to refuse to sign this document. You can choose to release only your public records, which includes: any final decision, award, or order of a workers222 compensation judge. However, if you choose to release all of your confidential workers222 compensation information, you MUST authorize the Office of Workers222 Compensation Administration to release your confidential records information to anyone not a party to your workers222 compensation claim. *This release must be attached to the Employee Workers222 Compensation Records Request Form. SECTI ON I: TO BE COMPLETED BY EMPLOYEE 1. Employee222s Full Name (Please Print) 2. Social Security Number 3. Street Address 4. Date of Birth 5. City, State, Zip 6. Phone Number 7. What records do you want to release? Only my workers222 compensation claim(s) information that is considered public record under La. R.S. 23:1293(B)(1) which only includes: final decision(s), award(s), or order(s) of a workers222 compensation judge. OR Any and all of my workers222 compensation claim(s) information, including confidential information, medical records, wage information, etc. in the possession of the Office of Workers222 Compensation Administration, Records Management. I understand that the Louisiana Workers222 Compensation Act, La. R.S. 23:1020.1, et seq., provides that certain information regarding prior work related injuries may be released to a requesting party. By signing this authorization, I hereby voluntarily authorize the State of Louisiana, Office of Workers222 Compensation Administration, Records Management Section to release only the information selected above in Section I and contained in my workers222 compensation records, if any, to the Recipient named in Section II. This release may contain public and non-public records in my workers222 compensation file(s) depending on my selection in Section I. This release is only for the recipient named in Section II and shall not be released to any third parties or any party not specifically named on this authorization. This authorization will expire thirty (30) days from the date of signature. Employee222s Signature Date SECTION II: RECORDS TO BE DISCLOSED TO 1. Name of Recipient (Please Print) 2. Company Name (if applicable) 3. Street Address 4. Phone Number 5. City, State, Zip 6. Please state Recipient222s relationship to the employee: * See Section III, Page 2. American LegalNet, Inc. www.FormsWorkFlow.com LWC-WC-1151 Page 2 of 2 Revised 8/1/17 SECTION II I : IF THE RECI PIENT IS A PROSPECTIVE EMPLOYER ** You must certify and sign the following: I hereby certify the information sought by this authorization is made on an applicant for employment only after a conditional job offer has been made and accepted, or on a current employee for a purpose which is job related and consistent with business necessity. I further certify the information obtained in the authorization will NOT be used to discriminate in any manner against the individual who is the subject of this authorization on any basis, in violation of the Americans with Disabilities Act of 1990, 42 U.S.C. 24712101, et seq., or any other state or federal law, as applicable. I am aware of the confidential and privileged nature of an employee222s Workers222 Compensation records, pursuant to La. R.S. 23: 1293. Employer222s Signature Date **MUST BE NOTARIZED PRIOR TO RECORDS REQUEST Sworn and subscribed before me this day of , 20 at , Louisiana. Notary Public222s Signature Print Name: Notary ID: My commission expires: American LegalNet, Inc. www.FormsWorkFlow.com