"Authorization for the Release of Subsequent Injury Fund Certification Status" - Montana

Authorization for the Release of Subsequent Injury Fund Certification Status is a legal document that was released by the Montana Department of Labor and Industry - a government authority operating within Montana.

Form Details:

  • Released on January 1, 2021;
  • The latest edition currently provided by the Montana Department of Labor and Industry;
  • Ready to use and print;
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  • Fill out the form in our online filing application.

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AUTHORIZATION FOR THE RELEASE OF
SUBSEQUENT INJURY FUND CERTIFICATION STATUS
The Subsequent Injury Fund is intended as an incentive to employers to hire and retain persons
having physical restrictions or impairments that may be a barrier to employment. Certification is
entirely voluntary and may NOT be used as a means of discrimination against you. In order to
receive the benefits of the Fund employers and insurers must be advised the worker has been
certified under the Fund. Please complete the following authorization if you would like to notify
any of the parties below.
I hereby authorize the Subsequent Injury Fund to release my certification status to the following:
(please check one or more)
_______ Employer
_______ Insurer or third party administrator
_______ Vocational Rehabilitation provider
_______ Other:_______________________________________
NOTE: This authorization will allow the Fund to disclose whether or not you have been certified
under the Fund. The Fund will not disclose any medical information to the parties listed above.
I may withdraw this consent by giving written notification of withdrawal to the Subsequent
Injury Fund. The date for withdrawal will be the date written notification is received by the
Fund, and any action taken by the Fund based upon this consent prior to receipt of my written
withdrawal is expressly authorized.
DATED:____________________________________________________________
SIGNATURE:_________________________________________________________
TYPE OR PRINT NAME:________________________________________________
NOTE: This release is good for 1 year from the date it is originally signed.
Revised 01/2021
AUTHORIZATION FOR THE RELEASE OF
SUBSEQUENT INJURY FUND CERTIFICATION STATUS
The Subsequent Injury Fund is intended as an incentive to employers to hire and retain persons
having physical restrictions or impairments that may be a barrier to employment. Certification is
entirely voluntary and may NOT be used as a means of discrimination against you. In order to
receive the benefits of the Fund employers and insurers must be advised the worker has been
certified under the Fund. Please complete the following authorization if you would like to notify
any of the parties below.
I hereby authorize the Subsequent Injury Fund to release my certification status to the following:
(please check one or more)
_______ Employer
_______ Insurer or third party administrator
_______ Vocational Rehabilitation provider
_______ Other:_______________________________________
NOTE: This authorization will allow the Fund to disclose whether or not you have been certified
under the Fund. The Fund will not disclose any medical information to the parties listed above.
I may withdraw this consent by giving written notification of withdrawal to the Subsequent
Injury Fund. The date for withdrawal will be the date written notification is received by the
Fund, and any action taken by the Fund based upon this consent prior to receipt of my written
withdrawal is expressly authorized.
DATED:____________________________________________________________
SIGNATURE:_________________________________________________________
TYPE OR PRINT NAME:________________________________________________
NOTE: This release is good for 1 year from the date it is originally signed.
Revised 01/2021