DATA RELEASE FORM

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

Employee Name: __________________________________

File Number:   __________________________________

Assigned Claims Examiner:__________________________________

Date of Request for File

Copy:                   __________________________________

Name of Requestor:      __________________________________

File Copy to be Sent to:__________________________________

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.

_________________________________________   ___________

(CE, CE2, FAB, or NO Representative)       (Date)

_________________________________________   ___________

(Final Reviewer)                           (Date)