AUTHORIZATION TO DISCLOSE CONFIDENTIAL WORKERS' COMPENSATION INFORMATION Michigan Department of Licensing and Regulatory Affairs Workers' Compensation Agency PO Box 30016, Lansing, MI 48909 VOLUNTARILY PAID CLAIMS (CLAIMS THAT ARE NOT A "CONTESTED CASE") RECORDS ARE EXEMPT FROM DISCLOSURE UNDER THE FREEDOM OF INFORMATION ACT AND THE WORKERS' DISABILITY COMPENSATION ACT. RECORDS/INFORMATION REGARDING THESE CLAIMS CANNOT BE RELEASED WITHOUT A RECORDS RELEASE AUTHORIZATION SIGNED BY THE CLAIMANT. Please type or print legibly - Illegible documents will not be processed 1. Claimant's Full Name 2. Claimant's Street Address 3. City, State, ZIP Code 4. Claimant's Complete Social Security Number 5. Date of Birth I Authorize: Michigan Department of Licensing & Regulatory Affairs Workers' Compensation Agency PO Box 30016 Lansing, Michigan 48909-7516 To Disclose (check one): Any/all of my workers' compensation claim(s) information. My workers' compensation claim(s) information limited to that specifically described here: Records To Be Disclosed To (name and address): _________________________________________________ _________________________________________________ _________________________________________________ 6. Signature of Claimant (authorizing release of records described above) 7. Date 8. Signature of Person Requesting Records (if applicable) 9. Date LARA is an equal opportunity employer/program. Auxiliary aids, services and other reasonable accommodations are available upon request to individuals with disabilities. WC-155 (9/14) Authority: Michigan Freedom of Information Act (FOIA), 1976 PA 442, as amended American LegalNet, Inc. www.FormsWorkFlow.com