Form WCB-6 "Certificate Authorizing Release of Benefit Information" - Maine

What Is Form WCB-6?

This is a legal form that was released by the Maine Workers' Compensation Board - a government authority operating within Maine. As of today, no separate filing guidelines for the form are provided by the issuing department.

Form Details:

  • Released on September 1, 2020;
  • The latest edition provided by the Maine Workers' Compensation Board;
  • Easy to use and ready to print;
  • Quick to customize;
  • Compatible with most PDF-viewing applications;
  • Fill out the form in our online filing application.

Download a fillable version of Form WCB-6 by clicking the link below or browse more documents and templates provided by the Maine Workers' Compensation Board.

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Download Form WCB-6 "Certificate Authorizing Release of Benefit Information" - Maine

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STATE OF MAINE
WORKERS' COMPENSATION BOARD
27 STATE HOUSE STATION, AUGUSTA, MAINE 04333-0027
1. REVISION DATE:
2. WCB FILE NUMBER
CERTIFICATE AUTHORIZING
_____/_____/_____
(if known):
RELEASE OF BENEFIT INFORMATION
MM
DD
YYYY
EMPLOYEE
3. EMPLOYEE LAST NAME:
4. FIRST NAME:
5. MI.:
6. SOCIAL SECURITY NUMBER (last 4 digits):
XXX-XX-
7. STREET/P.O. BOX MAILING ADDRESS:
8. CITY:
9. STATE:
10. ZIP:
11. HOME PHONE NUMBER:
12. DATE OF INJURY:
13. SPECIFIC INJURY OR ILLNESS:
14. BODY PARTS (S) AFFECTED:
_____/_____/_____
MM
DD YYYY
EMPLOYER/INSURER
15. INSURER FILE NUMBER:
16. EMPLOYER NAME:
17. EMPLOYER MAILING ADDRESS AND PHONE NUMBER:
18. INSURER NAME:
19. INSURER MAILING ADDRESS AND PHONE NUMBER:
PART II (COMPLETED BY EMPLOYEE)
I, _________________________________________________, DATE OF BIRTH ______________ AUTHORIZE THE EMPLOYER/INSURER TO OBTAIN
WRITTEN INFORMATION INDICATING THE NATURE AND AMOUNT OF BENEFITS I RECEIVED OR AM RECEIVING FROM THE FOLLOWING:
SOCIAL SECURITY ADMINISTRATION
EMPLOYEE BENEFITS PLAN
NAME OF EMPLOYEE BENEFIT PLAN
ADDRESS- NUMBER AND STREET
CITY, STATE, ZIP
I UNDERSTAND THAT THE EMPLOYER/INSURER IS ENTITLED TO RECEIVE THIS SOCIAL SECURITY OLD AGE INSURANCE OR EMPLOYEE
BENEFIT PLAN INFORMATION PURSUANT TO 39-A M.R.S.A. §221(5) AND THAT MY FAILURE TO COMPLETE AND RETURN THIS REPORT MAY
AFFECT MY WORKERS' COMPENSATION INDEMNITY BENEFITS. THIS CERTIFICATE OF RELEASE IS VALID FOR ONE YEAR FROM THE DATE OF
MY SIGNATURE.
SIGNATURE: _________________________________________________
DATE: _____________________
PART III (COMPLETED BY SOCIAL SECURITY ADMINISTRATION OR EMPLOYEE BENEFIT PLAN ADMINISTRATOR)
THE EMPLOYEE AUTHORIZES THE RELEASE OF BENEFIT INFORMATION PURSUANT TO 39-A M.R.S.A. §221(5). PLEASE PROVIDE THE
FOLLOWING INFORMATION TO THE EMPLOYER/INSUER:
1.
EFFECTIVE DATE OF ELIGIBILITY: _____________________________________
2.
CURRENT GROSS MONTHLY AMOUNT: __________________________________
3.
PERCENTAGE OF EMPLOYEE BENEFIT PLAN PAID BY EMPLOYER (IF APPLICABLE): ________________________
4.
IF BENEFITS FROM THIS EMPLOYEE BENEFIT PLAN ARE SUBJECT TO REDUCTION BASED ON RECEIPT OF WORKERS’
COMPENSATION BENEFITS, PLEASE EXPLAIN:
5.
COMMENTS:
6.
BENEFIT INFORMATION SENT TO THE EMPOYER/INSURER ON: ___________________________
DATE: _____________________
SIGNATURE: _________________________________________________
DATE: ____________________
PREPARER NAME (TYPE OR PRINT): _______________________________
TELEPHONE NUMBER: __________________________
The State of Maine provides equal opportunity in employment and programs. Auxiliary aids and services are available to individuals with
disabilities upon request.
For assistance with this form, contact the ADA Coordinator at the Maine Workers’ Compensation Board.
Telephone: 1-888-801-9087 or TTY Maine Relay 711.
WCB-6 (effective 9/1/2020)
STATE OF MAINE
WORKERS' COMPENSATION BOARD
27 STATE HOUSE STATION, AUGUSTA, MAINE 04333-0027
1. REVISION DATE:
2. WCB FILE NUMBER
CERTIFICATE AUTHORIZING
_____/_____/_____
(if known):
RELEASE OF BENEFIT INFORMATION
MM
DD
YYYY
EMPLOYEE
3. EMPLOYEE LAST NAME:
4. FIRST NAME:
5. MI.:
6. SOCIAL SECURITY NUMBER (last 4 digits):
XXX-XX-
7. STREET/P.O. BOX MAILING ADDRESS:
8. CITY:
9. STATE:
10. ZIP:
11. HOME PHONE NUMBER:
12. DATE OF INJURY:
13. SPECIFIC INJURY OR ILLNESS:
14. BODY PARTS (S) AFFECTED:
_____/_____/_____
MM
DD YYYY
EMPLOYER/INSURER
15. INSURER FILE NUMBER:
16. EMPLOYER NAME:
17. EMPLOYER MAILING ADDRESS AND PHONE NUMBER:
18. INSURER NAME:
19. INSURER MAILING ADDRESS AND PHONE NUMBER:
PART II (COMPLETED BY EMPLOYEE)
I, _________________________________________________, DATE OF BIRTH ______________ AUTHORIZE THE EMPLOYER/INSURER TO OBTAIN
WRITTEN INFORMATION INDICATING THE NATURE AND AMOUNT OF BENEFITS I RECEIVED OR AM RECEIVING FROM THE FOLLOWING:
SOCIAL SECURITY ADMINISTRATION
EMPLOYEE BENEFITS PLAN
NAME OF EMPLOYEE BENEFIT PLAN
ADDRESS- NUMBER AND STREET
CITY, STATE, ZIP
I UNDERSTAND THAT THE EMPLOYER/INSURER IS ENTITLED TO RECEIVE THIS SOCIAL SECURITY OLD AGE INSURANCE OR EMPLOYEE
BENEFIT PLAN INFORMATION PURSUANT TO 39-A M.R.S.A. §221(5) AND THAT MY FAILURE TO COMPLETE AND RETURN THIS REPORT MAY
AFFECT MY WORKERS' COMPENSATION INDEMNITY BENEFITS. THIS CERTIFICATE OF RELEASE IS VALID FOR ONE YEAR FROM THE DATE OF
MY SIGNATURE.
SIGNATURE: _________________________________________________
DATE: _____________________
PART III (COMPLETED BY SOCIAL SECURITY ADMINISTRATION OR EMPLOYEE BENEFIT PLAN ADMINISTRATOR)
THE EMPLOYEE AUTHORIZES THE RELEASE OF BENEFIT INFORMATION PURSUANT TO 39-A M.R.S.A. §221(5). PLEASE PROVIDE THE
FOLLOWING INFORMATION TO THE EMPLOYER/INSUER:
1.
EFFECTIVE DATE OF ELIGIBILITY: _____________________________________
2.
CURRENT GROSS MONTHLY AMOUNT: __________________________________
3.
PERCENTAGE OF EMPLOYEE BENEFIT PLAN PAID BY EMPLOYER (IF APPLICABLE): ________________________
4.
IF BENEFITS FROM THIS EMPLOYEE BENEFIT PLAN ARE SUBJECT TO REDUCTION BASED ON RECEIPT OF WORKERS’
COMPENSATION BENEFITS, PLEASE EXPLAIN:
5.
COMMENTS:
6.
BENEFIT INFORMATION SENT TO THE EMPOYER/INSURER ON: ___________________________
DATE: _____________________
SIGNATURE: _________________________________________________
DATE: ____________________
PREPARER NAME (TYPE OR PRINT): _______________________________
TELEPHONE NUMBER: __________________________
The State of Maine provides equal opportunity in employment and programs. Auxiliary aids and services are available to individuals with
disabilities upon request.
For assistance with this form, contact the ADA Coordinator at the Maine Workers’ Compensation Board.
Telephone: 1-888-801-9087 or TTY Maine Relay 711.
WCB-6 (effective 9/1/2020)