Form WC190 "Authorization for Release of Limited Information to Third Parties" - Colorado

What Is Form WC190?

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;

Download a fillable version of Form WC190 by clicking the link below or browse more documents and templates provided by the Colorado Department of Labor and Employment.

ADVERTISEMENT
ADVERTISEMENT

Download Form WC190 "Authorization for Release of Limited Information to Third Parties" - Colorado

558 times
Rate (4.7 / 5) 28 votes
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
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