North Dakota > Workers Comp
Release Of Information For WSI Authorization SFN 50381 - North Dakota
| Release Of Information For WSI Authorization Form. This is a North Dakota form and can be used in Workers Comp . |
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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
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