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 do not contain Personally Identifiable Information (PII) of other individuals aside from the requestor or any PII that has been redacted.

 

 

 

_________________________________________            ___________

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

 

 

 

_________________________________________            ___________

(Final Reviewer)                                     (Date)