State of Arizona

Authorization to Release Information

	To be completed by the Applicant
	Name:
	Social Security Number:			-		-
	Date of Birth:		/		/
	I authorize the State of Arizona, Department of Industrial Commission, to release information regarding work-related injuries, including first reports of injury and both pending and closed worker’s comp claim cases on file with the State Department of Workers’ Compensation to , an agent for
(Employer)
	This information may include, but should not be limited to case, claim or identification, number, date of injury, source of injury, type of injury, nature of injury, employer involved in the claim, compensation and medical dollars paid, and status.
		(Signature)					(Date)
	To be completed by the Employer
	A conditional offer of employment has been extended to the above named individual, as required by the Americans with Disabilities Act.
	Employer’s Name:
	Employer’s Address:
	Authorized Signature:							Date: