Form WC 190 Authorization for Release of Limited Information to Third Parties - Colorado

Form WC190 or the "Authorization For Release Of Limited Information To Third Parties" is a form issued by the Colorado Department of Labor and Employment.

The form was last revised in June 1, 2018 and is available for digital filing. Download an up-to-date Form WC190 in PDF-format down below or look it up on the Colorado Department of Labor and Employment Forms website.

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COLORADO DEPARTMENT OF LABOR AND EMPLOYMENT
Division of Workers’ Compensation
th
633 17
Street, Suite 400
Denver, CO 80202-3660
Phone: (303) 318-8700 | Toll Free: (888) 390-7936
Fax: (303) 318-8710
AUTHORIZATION FOR RELEASE OF LIMITED INFORMATION TO THIRD PARTIES
Claimant Social Security Number:
Claimant Name:
Requestor (Third Party) Name:
Employer Business Name:
The above referenced claimant authorizes limited access to above-mentioned requestor to all workers’ compensation
files on record as stated below. 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.
Information provided shall be limited to:
Workers’ Compensation Number
Date of Injury
Part of Body
Employer
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.
STATE OF
When using an embossed seal, please shade before faxing.
COUNTY OF
Subscribed and sworn to before me this
day of
,
20
by
(Print name of claimant)
Place notary seal here
Signature of Notary Public
My commission expires:
Altered forms will not be accepted.
WC 190 Rev. 06/18
Clear Entire Form
COLORADO DEPARTMENT OF LABOR AND EMPLOYMENT
Division of Workers’ Compensation
th
633 17
Street, Suite 400
Denver, CO 80202-3660
Phone: (303) 318-8700 | Toll Free: (888) 390-7936
Fax: (303) 318-8710
AUTHORIZATION FOR RELEASE OF LIMITED INFORMATION TO THIRD PARTIES
Claimant Social Security Number:
Claimant Name:
Requestor (Third Party) Name:
Employer Business Name:
The above referenced claimant authorizes limited access to above-mentioned requestor to all workers’ compensation
files on record as stated below. 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.
Information provided shall be limited to:
Workers’ Compensation Number
Date of Injury
Part of Body
Employer
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.
STATE OF
When using an embossed seal, please shade before faxing.
COUNTY OF
Subscribed and sworn to before me this
day of
,
20
by
(Print name of claimant)
Place notary seal here
Signature of Notary Public
My commission expires:
Altered forms will not be accepted.
WC 190 Rev. 06/18

Download Form WC 190 Authorization for Release of Limited Information to Third Parties - Colorado

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