DATA RELEASE FORM

 

FOR ALL FILE COPY REQUESTS:  This form must be completed and placed on the spindle in the claim file.

 

 

Claim File Employee Name:       ____________________________________

 

Claim File Employee SSN:        ____________________________________

 

Assigned Claims Examiner:       ____________________________________

 

Date of request for file copy:     ____________________________________

 

Initial Reviewer Name:               ____________________________________

 

Initial Review Date:                   ____________________________________

 

Final Reviewer Name:                ____________________________________

 

Final Review Date:           ____________________________________

 

 

 

I have carefully reviewed the documents and/or electronic media being sent pursuant to this claimant request for a copy of file documents.  To the best of my knowledge these documents and/or electronic media does not contain Personally Identifiable Information (PII) or any PII has been redacted.

 

 

 

_________________________________________          ___________

(Claims Examiner or Hearing Representative)                         (Date)

 

 

_________________________________________           ___________

(Senior Claims Examiner  )                                                     (Date)