Waiver For Release Of Records
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Waiver For Release Of Records Form. This is a Iowa form and can be use in Workers Compensation.
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Tags: Waiver For Release Of Records, 14-0169, Iowa Workers Compensation,
Waiver for Release of Records
I, the undersigned employee, authorize the Iowa Division of Workers'
Compensation to release to:
_____________________________________________________________ .
(Name of authorized recipient)
the categories of confidential records that are checked below, that are in the
division’s custody and that contain information that identifies me.
____ All confidential records of any nature
____ First Reports of Injury (FROI) (screen prints) filed within the past ____ years
____ Subsequent Reports of Injury (SROI) (screen prints) filed within the past ____
years
____ Evidence received in a contested case hearing
____ The transcript from a contested case hearing
____ Other (describe specific records to release) _________________________
___________________________________________________________
___________________________________________________________
Signed at________________________ this ___ day of______________, 20___.
(City, State)
(Print Name)
Employee
(Signature)
To identify me and calls to verify that I signed this waiver, I provide my:
Social security number: _____________________________________________
Date of Birth: _____________________________________________________
Address: _________________________________________________________
Telephone number: ________________________________________________
14-0169 (7-05)
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