Authorization For Rehabilitation Professional To Obtain Medical Records Of Current Treatment
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Authorization For Rehabilitation Professional To Obtain Medical Records Of Current Treatment Form. This is a North Carolina form and can be use in Workers Comp.
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Tags: Authorization For Rehabilitation Professional To Obtain Medical Records Of Current Treatment, 25C, North Carolina Workers Comp,
North Carolina Industrial Commission
IC File #
AUTHORIZATION FOR REHABILITATION PROFESSIONAL
TO OBTAIN MEDICAL RECORDS OF CURRENT TREATMENT
Emp. Code #
Carrier Code #
Carrier
File #
The Use Of This Form Is Required Under The Provisions of The Workers' Compensation Act
Employer FEIN
(
Employee’s Name
Employer's Name
Address
Employer’s Address
City
Zip
)
-
(
Home Telephone
-
)
M
(
Social Security Number
F
Sex
City
State
City
Zip
State
-
Work Telephone
-
-
Insurance Carrier
/
State
(
)
Telephone Number
Carrier’s Address
/
Date of Birth
)
Zip
-
(
)
Carrier's Telephone Number
I,
Fax Number
, the employee-claimant, hereby authorize the
(Please Print)
release of all my medical records of treatment resulting from a work-related injury/occupational
disease that occurred/was contracted on
to the Rehabilitation
(Please Print)
Professional assigned to me. That Rehabilitation Professional is:
Name:
Address:
Telephone: (
)
-
/
Employee’s Signature
/
Date
NOTE: THE REFUSAL OF THE CLAIMANT TO SIGN THIS FORM UPON THE REQUEST OF THE REHABILITATION
PROFESSIONAL MAY BE DEEMED BY THE INDUSTRIAL COMMISSION TO BE NONCOMPLIANCE WITH
REHABILITATION AND MAY RESULT IN THE SUSPENSION OF BENEFITS.
PLEASE MAIL THIS COMPLETED FORM TO THE REHABILITATION PROFESSIONAL NAMED ABOVE.
FORM 25C
1/2004
PAGE 1 OF 1
FORM 25C
NORTH CAROLINA INDUSTRIAL COMMISSION
MAIN TELEPHONE: (919) 807-2500
HELPLINE: (800) 688-8349
WEBSITE: HTTP://WWW.IC.NC.GOV/
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