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)