MISSOURI DEPARTMENT OF LABOR AND INDUSTRIAL RELATIONS AUTHORIZATION TO INSPECT AND/OR COPY MEDICAL RECORDS Injury Number 3315 W. Truman Blvd. P.O. Box 58 Jefferson City, MO 65102-0058 573-751-4231 www.labor.mo.gov/DWC Checked By TO: Employee Employer Insurer Date of Accident Place and County of Accident Description of Injury (Must include part of body affected) You are hereby authorized to permit (NAME) in behalf of , to inspect and/or copy any and all medical (PARTY) records you have in your possession in regard to the above captioned case, which is now pending before the Division of Workers’ Compensation. NOTE: The medical records which may be released according to this authorization are limited to medical treatment for the injury suffered on the date of accident listed above. ONLY records that relate to the injury listed above, as to the type of injury and the part of the body injured, may be included. Medical records from before the date of accident or medical records after the date of accident, which do not relate to this injury, may not be released pursuant to this authorization. This authorization is made in accordance with Section 287.140.7, RSMo., which reads as follows: “Every hospital or other person furnishing the employee with medical aid shall permit its record to be copied by and shall furnish full information to the division or the commission, the employer, the employee or his dependents and any other party to any proceedings for compensation under this chapter, and certified copies of the records shall be admissible in evidence in any such proceedings.” Date APPROVED BY: Administrative Law Judge Signature (Division of Workers’ Compensation) This form is effective twelve months from the date it is signed by an Administrative Law Judge. WC-43 (03-12) AI American LegalNet, Inc. www.FormsWorkFlow.com