I understand that signing this Authorization is voluntary and that if I do not sign this form, it will not affect my treatment,
payment, enrollment in a health plan, or eligibility for benefits; however, if I do not sign, the Benefits Managers may not
be able to carry out the Purpose for this Authorization, including but not limited to handling my claim, job accommodation,
or finding out whether I am eligible for benefits, which may result in the delay or denial of my request for benefits or
accommodation, among other consequences.
________________________________________
_____________________
Signature of Claimant or Legal Representative
Date
________________________________________________
________________________________________________
Name of Legal Representative (if any)
Legal Representative’s Relationship to Claimant
(i.e.Attorney,LegalGuardian,etc
2