Departmental Accident Report Form Page 2
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2H U M A N R ES O U R C ES
Self Insured Workers’ Compensation Program
Employee’s Authorization for Release of Medical Information
To Whom It May Concern:
I hereby request and authorize any licensed physician, medical practitioner, hospital, clinic or other medical or medically related facility,
insurance company, or other organization, institution, or person that has any records or knowledge of me, to disclose, whenever requested to
do so, by GAB Robins as the third party administrator for the self insured employer, Columbia University, any and all such information.
A photocopy of this authorization shall be considered as effective and valid as the original.
/
/
Date of Birth:
Last Name:
First Name:
Address:
Apt. #:
City, State, ZIP:
Home Phone: (
)
–
Work Phone: (
)
–
Signature:
Date (mm/dd/yyyy):
Please send all medical records to:
GAB Robins
th
123 William Street, 15
Floor
New York, NY 10038
Phone: 212-815-8900
Fax: 212-732-5509
8/08
HR Benefits Service Center: (212) 851-7000 |
hrdisability@columbia.edu
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