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State Of Connecticut Workers' Compensation Commission - Employee'S Authorization To Release Information

State of Connecticut

Workers’ Compensation Commission

Employee’s Authorization to Release Information

, have

been

offered

job

with

, and hereby authorize the release of

Information verifying any worker’s compensation claim I may have in the State of Connecticut to the said employer.

I understand that the employer is prohibited from requesting this information until I have received a conditional

offer of employment (copy of written offer enclosed).

I further understand that my signature authorizes the Connecticut Workers’ Compensation Commission to furnish

information regarding any previous Worker’s Compensation claims I have filed in the state of Connecticut and that the

information provided will be limited to: (1) whether or not a claim has been filed by the above-named employee, (2) the

date of such injury, and (3) the nature of injury. No other information will be provided. Under no circumstances will

any Commissioners’ notes, medical reports, personnel records, or psychiatric records be released. Medical reports,

personnel records or psychiatric records will not be released without the claimant’s express authorization and not as the

result of this authorization.

Employee’s Signature:

Date:

Print Your Name:

Social Security #:

Instructions to Requester:

This form must be submitted to a district office of the Connecticut Worker’s Compensation Commission with the

employee’s original signature – a photo copy or faxed signature will not be accepted. A copy of the applicant’s

conditional offer letter must accompany this form.

The above is limited to: (1) whether or not a claim has been filed by the above-named employee, (2) the date of such

injury, and (3) the nature of injury. No other information will be provided.

WCC ONLY:

( ) Search was negative.

Years searched

( ) Search was positive

WCC File #

WCC Processor:

District Office #:

State Of Connecticut Workers' Compensation Commission - Employee'S Authorization To Release Information