Utah > Workers Compensation
Authorization To Release Industrial Accident Division Records 205 - Utah
| Authorization To Release Industrial Accident Division Records Form. This is a Utah form and can be used in Workers Compensation . |
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Print Form Form 205 AUTHORIZATION TO RELEASE INDUSTRIAL ACCIDENT DIVISION RECORDS PLEASE PRINT OR TYPE I hereby authorize and request that you release all records pertaining to my industrial injury(s) or illness(s) in your possession. I authorize the Industrial Accidents Division to release this information to the requesting party, for the purposes of verifying, evaluating, and managing my industrial claim. By signing this form the claimant is put on notice that his/her records, including medical records, are being made available to the requesting party. This form complies with the state Government Records Access & Management Act (GRAMA). Records Requested: Date of Injury Listed Only Records for All Injuries (give specific time frame): ________________________________________ PHOTOCOPIES OF THIS AUTHORIZATION ARE AS VALID AS THE ORIGINAL. Subscribed and sworn to before me this ____ day of _________________ 20_____ ____________________________________ NOTARY PUBLIC Residing at: __________________________ ____________________________________ ____________________________________ My Commission Expires: __________________________________________ Signature of Claimant __________________________________________ Claimant's Name (Printed) __________________________________________ Street Address __________________________________________ City/State/Zip __________________________________________ Telephone Number __________________________________________ Date of Birth __________________________________________ Social Security Number __________________________________________ Date of Injury/Occupational Disease THIS IS NOT A RELEASE OF CLAIM FOR DAMAGES Requester's Name________________________________ Signature ___________________________ (print) Mail Records To __________________________________________ Date ________________________________________ Street Address _________________________________________________________________________________________ City/ State/ Zip _________________________________________________________________________________________ Telephone Number ____________________________________________________________________ The Industrial Accidents charge for the search of these records is $15.00 to start the search plus $.50 per copy of any records copied. Official Form 205 Revised 2/09 State of Utah Labor Commission Division of Industrial Accidents 160 East 300 South P.O. Box 146610 Salt Lake City, UT 84114-6610 Telephone: (801) 530-6800 Fax: (801) 530-6804 Toll Free: (800) 530-5090 www.laborcommission.utah.gov American LegalNet, Inc. www.FormsWorkFlow.com
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