Authorization For Release Of Information {WC189}

COLORADO DEPARTMENT OF LABOR AND EMPLOYMENTDivision of Workers222 Compensation633 17th Street, Suite 400Denver, CO 80202-3660Phone: AUTHORIZATION FOR RELEASE OF INFORMATIONSocial Security Number: Claimant Name: Requestor Name: The claimant named in the above captioned matter hereby authorizes the above mentioned requestor to have or sections): Complete access All information except for medical or vocational rehabilitation reports þ Other þ þ claimant)Authorization must be signed and dated by the þ When using an embossed seal, please shade before faxingSTATE OF þ COUNTY OF þ Subscribed and sworn to before me this day of þ , 20 þ . by þ claimant) Signature of Notary Public My commission expires: Altered forms will not beaccepted.WC 189 Rev. 0 Place notary seal here American LegalNet, Inc. www.FormsWorkFlow.com