Release Of Information For WSI Authorization
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Release Of Information For WSI Authorization Form. This is a North Dakota form and can be use in Workers Comp.
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Tags: Release Of Information For WSI Authorization, SFN 50381, North Dakota Workers Comp,
RELEASE OF INFORMATION
CLAIMS DIVISION
SFN 50381 (05/2008)
1600 EAST CENTURY AVENUE, SUITE 1
PO BOX 5585
BISMARCK ND 58506-5585
Telephone 1-800-777-5033
Toll Free Fax 1-888-786-8695
TTY (hearing impaired) 1-800-366-6888
Fraud and Safety Hotline 1-800-243-3331
www.WorkforceSafety.com
PLEASE PRINT OR TYPE USING BLACK OR BLUE INK
Injured Worker’s Name
Claim Number
Social Security Number
Date of Birth
I authorize Workforce Safety & Insurance to release the following records:
All information and records on file
Correspondence only
Medical records only
Rehabilitation reports only
Compensation and medical payment information only
School records (including grades and attendance)
Other (please specify)
Please release these records to:
A copy of this authorization is considered as valid as the original and is in effect until revoked by me.
Date
Injured Worker’s Signature
Address
City
State
Zip
C57b
American LegalNet, Inc.
www.FormsWorkFlow.com
