Form WC189 "Authorization for Release of Information" - Colorado

What Is Form WC189?

This is a legal form that was released by the Colorado Department of Labor and Employment - a government authority operating within Colorado. As of today, no separate filing guidelines for the form are provided by the issuing department.

Form Details:

  • Released on June 1, 2018;
  • The latest edition provided by the Colorado Department of Labor and Employment;
  • 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 WC189 by clicking the link below or browse more documents and templates provided by the Colorado Department of Labor and Employment.

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Download Form WC189 "Authorization for Release of Information" - Colorado

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COLORADO DEPARTMENT OF LABOR AND EMPLOYMENT
Division of Workers’ Compensation
633 17th Street, Suite 400
Clear Form
Denver, CO 80202-3660
Phone: (303) 318-8700 | Toll Free: (888) 390-7936
Fax: (303) 318-8710
AUTHORIZATION FOR RELEASE OF INFORMATION
Social Security Number:
Claimant Name:
Requestor Name:
The claimant named in the above captioned matter hereby authorizes the above mentioned requestor to have
access to this workers’ compensation file. This authorization shall remain in effect for ninety days from the date
of claimant’s signature, unless claimant notifies the Division of Workers’ Compensation in writing before such
time, that claimant is revoking said authorization. Access to information is as follows (check applicable section
or sections):
Complete access
All information except for medical or vocational rehabilitation reports
Other
Claimant’s Signature (in presence of notary)
Date Signed (to be completed by claimant)
Authorization must be signed and dated by the claimant.
Notarization is required.
When using an embossed seal, please shade before faxing
STATE OF
COUNTY OF
Subscribed and sworn to before me this
.
,
day of
20
by
Place notary seal here
(Print name of claimant)
Signature of Notary Public
My commission expires:
Altered forms will not be accepted.
WC 189 Rev. 06/18
COLORADO DEPARTMENT OF LABOR AND EMPLOYMENT
Division of Workers’ Compensation
633 17th Street, Suite 400
Clear Form
Denver, CO 80202-3660
Phone: (303) 318-8700 | Toll Free: (888) 390-7936
Fax: (303) 318-8710
AUTHORIZATION FOR RELEASE OF INFORMATION
Social Security Number:
Claimant Name:
Requestor Name:
The claimant named in the above captioned matter hereby authorizes the above mentioned requestor to have
access to this workers’ compensation file. This authorization shall remain in effect for ninety days from the date
of claimant’s signature, unless claimant notifies the Division of Workers’ Compensation in writing before such
time, that claimant is revoking said authorization. Access to information is as follows (check applicable section
or sections):
Complete access
All information except for medical or vocational rehabilitation reports
Other
Claimant’s Signature (in presence of notary)
Date Signed (to be completed by claimant)
Authorization must be signed and dated by the claimant.
Notarization is required.
When using an embossed seal, please shade before faxing
STATE OF
COUNTY OF
Subscribed and sworn to before me this
.
,
day of
20
by
Place notary seal here
(Print name of claimant)
Signature of Notary Public
My commission expires:
Altered forms will not be accepted.
WC 189 Rev. 06/18