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)