CLAIMANT'S AUTHORIZATION TO DISCLOSE WORKERS' …
Claimant's Signature (ink only - use blue ink if possible) Date. Failure to provide the information requested on this form will not result in the denial of your authorization, but may delay the ... board records to disclose such information to any person who is not otherwise lawfully entitled to obtain these records. 5. Any person who knowingly ...
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PLEASE READ CAREFULLY THE FOLLOWING …
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