Authorization Of Release Of Claims Information

AUTHORIZATION OF RELEASE OF CLAIMS INFORMATION. This The South Carolina Workers’ Compensation Commission form lets an employee or job candidate authorize the Commission to release their workers’ compensation claim records to a specified business. Records are normally private and available only to the injured worker, the employer, and their representatives; this form waives that privacy for the named recipient . The authorization may be revoked at any time in writing and otherwise expires one year from the date signed. Required fields include the recipient’s business name and mailing address, the signer’s name and address, last four digits of SSN, and signature/date. The form also includes an indemnity statement and notes that suspected misuse of personal information may be reported to the South Carolina Human Affairs Commission. Valid for one year from signature unless revoked in writing. Contains indemnity language for the Commission and information providers. For informational use only; not legal advice. www.FormsWorkflow.com