Authorization To Release Industrial Accident Division Records {205}

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______ ____________________________________ Residing at: __________________________ ____________________________________ NOTARY PUBLIC SEAL This Notarization is valid for 90 days from the signature date. _________________________________________ 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 Division charge for the search of their records is $15.00 to start the search plus $.25 per copy of any records copied. Official Form 205 Revised 1/16 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