Chapter 1 - FORM 1-15 : AUTHORIZATION FOR RELEASE OF WORKERS' COMPENSATION INFORMATION

• Jurisdiction: Colorado

Form 1-15: Authorization for Release of Workers' Compensation Information

STATE OF COLORADO DEPARTMENT OF LABOR AND EMPLOYMENT DIVISION OF WORKERS' COMPENSATION AUTHORIZATION FOR RELEASE OF INFORMATION TO THIRD PARTIES

Claimant Name __________

Claimant Social Security Number __________

Requestor (Third Party) Name: __________

Employer Name: __________

The above referenced claimant authorizes limited access to above-mentioned requestor to all workers' compensation files on record as stated below. This authorization shall remain in effect for ninety days from the date of claimant's signature, unless claimant notifies the Division of Workers' Compensation in writing before such time, that claimant is revoking said authorization.

Information provided shall be limited to:

• Workers' Compensation Number
• Date of Injury
• Part of Body
• Employer

__________
Claimant's Signature

__________
Date Signed (to be completed by claimant)

Authorization must be signed and dated by the claimant.

Notarization is required

STATE OF COLORADO

COUNTY OF DENVER

When using an embossed seal, please shade before faxing.

Subscribed and sworn to before me this ___ day of ___, 20___, by __________ (Print name of claimant).

__________
Signature of Notary Public

My commission expires: __________

[The form below should be submitted along with the above form.]

Company Name: __________ Job #: __________

Address: __________ Fax: (___) __________

Request for Release of Information From Division of Worker's Compensation

Date: __________ Page # ___ of ___

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NOTES ON USE:

These two forms were adapted from forms developed by the Colorado Division of Workers' Compensation, and they should be submitted together.