Form 205 - Authorization To Release Industrial Accidents Records - Utah Labor Commission
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1AUTHORIZATION TO RELEASE
Form 205
INDUSTRIAL ACCIDENT DIVISION RECORDS
Please Print or Type
I hereby authorize and request that you release all records pertaining to my industrial injury(s) or illness(s) in
your possession.
I authorize the Industrial Accidents Division to release this information to the requesting party, for the
purposes of verifying, evaluating, and managing my industrial claim.
By signing this form the claimant is put on notice that his/her records, including medical records, are being
made available to the requesting party. This form complies with the state Government Records Access &
Management Act (GRAMA).
Records Requested: Date of Injury Listed Only Records for All Injuries (give specific time frame)
________________________________________
PHOTOCOPIES OF THIS AUTHORIZATION ARE AS VALID AS THE ORIGINAL.
Subscribed and sworn to before me this
day of _________________ 20______
_________________________________________
Signature of Claimant
____________________________________
_________________________________________
Claimant’s Name (Printed)
Residing at: __________________________
_________________________________________
Street Address
____________________________________
_________________________________________
NOTARY PUBLIC SEAL
City/State/Zip
_________________________________________
Telephone Number
_________________________________________
Date of Birth
________________________________________
Social Security Number
_________________________________________
Date of Injury/Occupational Disease
This Notarization is valid for 90 days from the
signature date.
THIS IS NOT A RELEASE OF CLAIM FOR DAMAGES
Requester’s Name __________________________________________________________________
Signature _________________________________________________________________________
(print)
Mail Records To ___________________________________________Date ____________________________________
Street Address _____________________________________________________________________________________
City/ State/ Zip _____________________________________________________________________________________
Telephone Number _________________________________________________________________
The Industrial Accidents Division charge for the search of their records is $15.00 to start the search plus $.25 per copy of
any records copied.
Official Form 205
Revised 1/16
State of Utah * Labor Commission * Division of Industrial Accidents
160 East 300 South * P.O. Box 146610 Salt Lake City, UT 84114-6610 * Telephone: (801) 530-6800
Fax: (801) 530-6804 * Toll Free: (800) 530-5090 *
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