Authorization to Disclose Workers' Compensation Records 2026

1. Click ‘Get Form’ to open it in the editor.
2. Begin by filling in your name in the first section, authorizing the disclosure of your workers' compensation records. Ensure you include the last four digits of your social security number for identification.
3. In the next section, specify the individual or organization authorized to make the disclosure. Here, you will enter 'Missouri Department of Labor and Industrial Relations – Division of Workers' Compensation' along with their address.
4. Detail the type of records to be disclosed. Carefully review and strike through any records that should not be included, ensuring clarity on what information is shared.
5. Indicate any restrictions on record release by specifying a date range if applicable.
6. Initial where required to authorize or restrict disclosure of sensitive health information, ensuring you understand what is being shared.
7. Complete the final sections with your signature, printed name, date of birth, and address. If applicable, provide details about your legal representative.

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