Policy Text
I, , hereby authorize any person in possession and/or in
control of all records, including but not limited to medical, m ental health, drug and/or alcohol
treatment, employment, personnel , group insurance, and retireme nt records, to release those records to
an agent, designee or representat ive of the County of Sacrament o Workers' Compensation Office for
the purpose of photocopying, rev iew, investigation, inspection or evaluation of any claim filed against
the County of Sacramen to for Workers' Compensation benefits or any other benefits or damages.
This authorization shall become effective immediately and shall r e m a i n i n ef f e c t f or t hr e e ( 3) years
unless otherwise revoked in writin g. Photocopies of this author ization may be used with the same force
and effect as the original. I understand that I am entitled to a copy of this authorization.
Date: __________________ Employee Signature____________________ _____________________
Date of Birth: ____________________
SSN___________-___________-___________
7697 (WClO) ReviselllI2000
W o r k R e l e a s e A p p e n d i x A 2 / 0 6 . 0