Data Release Form
FOR ALL FILE COPY REQUESTS: This form must be completed and placed on the spindle in the claim file.
Employee Name: __________________________________
File Number: __________________________________
Assigned Claims Examiner: __________________________________
Date of Request for File Copy:__________________________________
Name of Requestor: __________________________________
File Copy to be Sent to: __________________________________
Initial Reviewer Name: __________________________________
Initial Review Date: __________________________________
Final Reviewer Name: __________________________________
Final Review Date: __________________________________
I have carefully reviewed the documents and/or electronic media being sent pursuant to this claimant request for a copy of file documents. To the best of my knowledge these documents and/or electronic media do not contain Personally Identifiable Information (PII) of other individuals aside from the requestor or any PII that has been redacted.
_________________________________________
(CE, CE2, FAB, or NO Representative)
___________
(Date)
_________________________________________
(Final Reviewer)
___________
(Date)