AUTHORIZATION FOR FILE REVIEW OR RELEASE OF COPIES OF WORKERS' COMPENSATION CLAIM FILE TO: Department of Labor and Industry Workers' Compensation File Review PO Box 64226 St. Paul, MN 55164-0226 (651) 284-5200 Fax: (651) 284-5731 F 0005 E DO NOT USE THIS SPACE I hereby authorize _________________________________________________ to review and/or receive copies of any or all parts of the Minnesota workers' compensation claim file(s) maintained by the Department of Labor and Industry (DLI) for the employee and date(s) of injury indicated below. EMPLOYEE EMPLOYER WID or SSN INSURER (if known) DATE(S) OF INJURY · Following receipt of this properly completed authorization, DLI may release information from the workers' compensation claim file about the above-named employee, employer and insurer, including the employee's worker identification number (WID) and social security number, that would not otherwise be accessible to the public. The WID is a unique number assigned by DLI to an injured worker and may be used instead of the employee's SSN. Once this information is released, DLI does not control how it is used or further distributed by the recipient. A copy of this authorization may be used in the same manner and with the same effect as the original document. This authorization is valid for six months from the date signed, or until this consent is withdrawn by notifying DLI in writing at the above address or facsimile number. I am authorized to sign this form because I am the: employee parent/guardian of a minor or incapacitated employee (if not the parent, attach a court order documenting guardianship) · · · Print name of person authorizing release Signature of person authorizing release employer (state title at employer): __________________________________ insurer (state title at insurer): ______________________________________ dependent of deceased employee (state relationship): __________________ Date signed representative of employee's estate (attach court order) representative of the DLI Special Compensation Fund NOTICE: Information concerning disability may not be used to make a job decision unless state or federal law permits use of this information. Unless authorized by state or federal law, any use or distribution of this information beyond that authorized by the subject of this data is prohibited. Questions concerning use of disability information may be directed to the Minnesota Department of Human Rights at (651) 296-5663 or 1-800-657-3704. American LegalNet, Inc. www.FormsWorkFlow.com MN FE0005 (6/11) INSTRUCTIONS FOR AUTHORIZATION TO REVIEW OR RELEASE COPIES OF MINNESOTA WORKERS' COMPENSATION CLAIM FILE Minnesota Statutes, § 176.231, subdivision 9 requires that information in a workers' compensation claim file maintained by the Department of Labor and Industry (department) may not be released without the authorization of the employee, employer, insurer, or dependent of the deceased employee. Minnesota Rules, part 5220.2880, subpart 1, requires an authorization to: · · · be in writing; be signed and dated within the last six months by the employee or legal guardian, employer, insurer, special compensation fund, or dependent of a deceased employee for the specified date of injury; and specify who is authorized to review the file. The department may ask for additional information to verify the identity of the person authorizing the release or the relationship of the person to a party to the claim. Claim file information may not be released over the telephone without this authorization in the department's file. The department will only copy or permit review of claim file information for the dates of injury indicated on the authorization. If the authorization is for all dates of injury for an employee, indicate "any and all" dates of injury. An employer or insurer must obtain an authorization from the employee to review a workers' compensation file for which it is not a party. This authorization must be signed and dated by an authorized person and filed with the Department of Labor and Industry by mail or in person. In Person: Department of Labor and Industry Workers' Compensation File Review 443 Lafayette Road N. St. Paul, MN 55155-4301 Mailing Address: Department of Labor and Industry Workers' Compensation File Review PO Box 64226 St. Paul, MN 55164-0226 If you have questions, the worker's compensation file review office can be reached at 651-284-5200; toll-free: 800-342-5354; and TTY: 651-297-4198. MN FE0005 (6/11) American LegalNet, Inc. www.FormsWorkFlow.com