North Carolina Industrial Commission IC File # AUTHORIZATION FOR REHABILITATION PROFESSIONAL Emp. Code # TO OBTAIN M EDICAL R ECORDS OF CURRENT TREATMENT Carrier Code # Carrier File # The Use Of This Form Is Required Under The Provisions of The Workers Compensation Act Employer FEIN ( ) - Employees Name Employers Name Telephone Number Address Employers Address City State Zip City State Zip Insurance Carrier ( ) - ( ) - Home Telephone Work Telephone Carriers Address City State Zip - - M F / / ( ) - ( ) - Social Security Number Sex Date of Birth Carriers Telephone Number Fax Number I, , 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: __________________________________________ Employees 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 NORTH CAROLINA INDUSTRIAL COMMISSION 1/2004 MAIN TELEPHONE : (919) 807-2500 FORM 25C PAGE 1 OF 1 OMBUDSMAN: (800) 688- 8349 American LegalNet, Inc. www.USCourtForms.com