Request To Erase (Redact) Medical Information From An Audio Recording
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Request To Erase (Redact) Medical Information From An Audio Recording Form. This is a Colorado form and can be use in Workers Comp.
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Tags: Request To Erase (Redact) Medical Information From An Audio Recording, WC34, Colorado Workers Comp,
Request to Erase (Redact) Medical Information from an Audio Recording
To:
Colorado Division of Workers’ Compensation
Attn: Customer Service Unit
633 17th Street, Suite 400
Denver, CO 80202-3626
W.C. No:
From:
Claimant name
Address:
Insurer/ Employer:
Claim No:
I, the injured worker, recently had an independent medical examination. I have received and listened to a
copy of the audio recording of that examination. During the examination I made statements concerning a
medical condition that I believe should remain private because the condition is not connected to my workers’
compensation claim. I am asking that the part(s) of the recording that contain this information be erased from
the recording.
In order for this request to be considered I must describe, in general, the medical information I believe was
private. I am not asking that any information included in the written report be erased. Since I believe this
information is private I do not want to provide too much detail, but I understand I must provide enough
information that a judge can find the discussion on the recording and decide whether it should remain private.
The information is not relevant to my workers’ compensation claim, and I am formally requesting that this
information be redacted (erased) from the audio recording.
The information is contained in the recording at time marker:______________________ (if available)
The following is a general description of information that I request be deleted from the recording:
Signature
I am providing this form to the Division of Workers’ Compensation along with a copy of the audio recording
and a copy of the written medical report. I understand that I must send a copy of just this completed form to
the doctor that examined me and to the adjuster or the insurer’s attorney handling my claim.
CERTIFICATE OF SERVICE: Copies of this document were placed in the U.S. Mail or hand-delivered to
the following parties this ___________of _______________, ___________.
List the names and addresses of all the persons copied:
Insurer/ Employer:
Examining Physician:
By:
Signature
WC34 08/09
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