Free Form 25C - North Carolina

North Carolina Industrial Commission

IC File # Emp. Code # Carrier Code # Carrier File #

AUTHORIZATION FOR REHABILITATION PROFESSIONAL TO OBTAIN MEDICAL RECORDS OF CURRENT TREATMENT
The Use Of This Form Is Required Under The Provisions of The Workers' Compensation Act

Employer FEIN

(
Employee's Name Address Employer's Name Employer's Address Insurance Carrier Carrier's Address City State City State

)

-

Telephone Number Zip

City

State

Zip

( -

) -

M

(

) F

Zip

Home Telephone Social Security Number

Work Telephone

/

/

(

)

-

(

)

Fax Number

Sex

Date of Birth

Carrier's Telephone Number

I,
(Please Print)

, the employee-claimant, hereby authorize the

release of all my medical records of treatment resulting from a work-related injury/occupational disease that occurred/was contracted on
(Please Print)

to the Rehabilitation

Professional assigned to me. That Rehabilitation Professional is:
Name: Address:

Telephone: (

)

-

/
Employee's Signature

/

Date

NOTE: THE REFUSAL OF THE CLAIMANT TO SIGN THIS FORM UPON THE REQUEST OF THE REHABILITATION PROFESSIONAL MAY BE DEEMED BY THE INDUSTRIAL COMMISSION TO BE NONCOMPLIANCE WITH REHABILITATION AND MAY RESULT IN THE SUSPENSION OF BENEFITS.

PLEASE MAIL THIS COMPLETED FORM TO THE REHABILITATION PROFESSIONAL NAMED ABOVE.

FORM 25C 1/2004 PAGE 1 OF 1

FORM 25C

NORTH CAROLINA INDUSTRIAL COMMISSION MAIN TELEPHONE: (919) 807-2500 HELPLINE: (800) 688-8349 WEBSITE: HTTP://WWW.IC.NC.GOV/