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
)
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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/