CERTIFICATE AUTHORIZING RELEASE OF INFORMATION STATE OF MAINE WORKERS' COMPENSATION BOARD STATION 27, AUGUSTA, MAINE 04333-0027 1. INSURER FILE NUMBER: 6. SOCIAL SECURITY NUMBER 7. WCB FILE NUMBER: (FOR OFFICE USE ONLY) 2. EMPLOYER NAME: 8. EMPLOYEE LAST NAME: 3. EMPLOYER MAILING ADDRESS AND PHONE NUMBER: 11. ADDRESS-NUMBER AND STREET: 4. INSURER NAME: 12. CITY: 5. INSURER MAILING ADDRESS: 16. DATE OF INJURY: 9. FIRST NAME: 13. STATE: 14. ZIP: 10. M.I.: 15. HOME PHONE: NOTICE TO RERQUESTING PARTY THIS CERTICATE COMPLIES WITH 39-A M.R.S.A. § 152 (2) AND RULE 16.3. IF YOUR REQUEST IS DENIED, YOU HAVE THE RIGHT TO APPEAL TO THE BOARD'S GENERAL COUNSEL WITHIN 30 DAYS OF THE DATE MAILED (BOX 23). THIS CERTIFICATE WILL BECOME PART OF THE BOARD'S FILE. 17. ESTABLISH YOUR NEED-TO-KNOW: A. INJURED PERSON AUTHORIZES DISCLOSURE. B. EMPLOYER OR INSURER OF AN INJURED PERSON REQUESTS DISCLOSURE THROUGH AN ATTORNEY OR OTHER AGENT. C. PERSON ASSERTS A WORKERS' COMPENSATION CLAIM OR FILES A LAWSUIT AND ANY OTHER PERSON SUBJECT TO LIABILITY FOR THE CLAIM REQUESTS DISCLOSURE DIRECTLY THROUGH AN ATTORNEY OR OTHER AGENT. D. PERSON, INSURER, EMPLOYER OR OTHER INVOLVED PARTY IS SUBJECT OF A PUBLIC AGENCY INVESTIGATION FOR FRAUD OR OTHER IMPROPRIETY, CIVIL OR CRIMINAL. E. A BOARD EMPLOYEE, SUCH AS A HEARING OFFICER, MEDIATOR, ARBITRATOR, AN APPOINTED OR AGREED UPON INDEPENDENT MEDICAL EXAMINER REQUESTS RECORDS FOR DECISION MAKING. F. HEARING OFFICER, MEDIATOR, ARBITRATOR OR GENERAL COUNSEL RULES THAT DISCLOSURE IS APPROPRIATE FOR ANY OTHER REASON. G. DISCLOSURE IS REQUIRED BY STATE OR FEDERAL LAW OR BY COURT ORDER (ATTACH COPY OF LAW OR COURT ORDER). 18. COMMENTS: 19. SPECIFIC INFORMATION REQUESTED: A. SCREEN PRINT CLAIMS INQUIRY 1. CLAIMS HISTORY B. FILE COPIES 1. FIRST REPORT 2. NOCS/PETS (TROUBLESHOOTING) 2. ALL BOARD FORMS 3. MEDIATION/FORMAL HEARING 3. BOARD DECISIONS 4. PAYMENTS 4. OTHER (SPECIFY) ____________________________________ 20. REQUESTING PARTY SIGNATURE (FORM MUST BE SIGNED): 21. DATE SIGNED: 22. APPROVED: YES NO (FOR OFFICE USE ONLY) AUTHORIZING SIGNATURE AND TITLE: __________________________________________ 23. DATE MAILED: (FOR OFFICE USE ONLY) THE STATE OF MAINE DOES NOT DISCRIMINATE ON THE BASIS OF DISABILITY IN ADMISSION TO, ACCESS TO, OR OPERATION OF ITS PROGRAMS, SERVICES, OR ACTIVITIES. THIS FORM IS AVAILABLE IN ALTERNATIVE FORMAT. FOR FURTHER ASSISTANCE, CONTACT THE MAINE WORKERS’ COMPENSATION BOARD, ADA COORDINATOR, TELEPHONE: 1-888-8019087 OR TTY (877) 832-5525 WCB 221 (5/95) DISTRIBUTION: COPY (1) WORKERS' COMPENSATION BOARD, (2) REQUESTING PARTY American LegalNet, Inc. www.USCourtForms.com