Release Of Information {SFN 50381}

RELEASE OF INFORMATION CLAIMS DIVISION SFN 50381 (08/2014) 1600 EAST CENTURY AVENUE, SUITE 1 PO BOX 5585 BISMARCK ND 58506-5585 Telephone 1-800-777-5033 Toll Free Fax 1-888-786-8695 TTY (hearing impaired) 1-800-366-6888 Fraud and Safety Hotline 1-800-243-3331 www.WorkforceSafety.com PLEASE PRINT OR TYPE USING BLACK OR BLUE INK Injured Worker's Name Social Security Number* Claim Number Date of Birth I authorize Workforce Safety & Insurance to release the following records: All information and records on file Correspondence only Medical records only Rehabilitation reports only Compensation and medical payment information only School records (including grades and attendance) Other (please specify) Please release these records to: A copy of this authorization is considered as valid as the original and is in effect until revoked by me. Injured Worker's Signature Date Address City State Zip * In compliance with the Federal Privacy Act of 1974, disclosure of the social security number on this form is mandatory pursuant to N.D.C.C. 65-05-02. The social security number is used for identification and verification purposes. Failure to provide this information may result in a delay in processing your request. C57b American LegalNet, Inc. www.FormsWorkFlow.com