Authorization to Release Industrial Accident Division Records - Utah: Fill out & sign online

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Click ‘Get Form’ to open the Authorization to Release Industrial Accident Division Records in our editor.
Begin by filling in your personal information. Enter your name, address, telephone number, date of birth, and social security number in the designated fields.
Specify the records you wish to request. You can choose either 'Date of Injury Listed Only' or 'Records for All Injuries' and provide a specific time frame if applicable.
Sign the form where indicated. Ensure that your signature matches the printed name above it.
Complete the requester’s section by providing their name, signature, and mailing address for the records.
Review all entered information for accuracy before finalizing your document.

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