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SSN (last 4 digits): XXX-XX-

SSN (last 4 digits): XXX-XX- 2026

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The document is a limited release form for medical and health care information required by the State of Maine Workers' Compensation Board. It authorizes health care providers to release specific medical records related to an employee's injury or illness to the employer or insurer for the purpose of determining compensability of a workers' compensation claim. The form outlines the rights of the employee, including the voluntary nature of completion, limitations on the information released, and conditions under which the authorization can be revoked.

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Click ‘Get Form’ to open it in the editor.
Begin by entering your name in the designated field at the top of the form. This is essential for identifying your records.
Next, locate the section labeled 'SSN (last 4 digits): XXX-XX-'. Enter the last four digits of your Social Security Number carefully to ensure accuracy.
Proceed to fill in your date of birth and date of injury/illness in their respective fields. These details are crucial for processing your claim.
In the body part(s) and/or condition(s) section, clearly specify any relevant medical conditions or body parts related to your claim.
Review all entered information for accuracy before finalizing. Once satisfied, you can save or export the document directly from our platform.

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Versions	Form popularity	Fillable & printable
2018	4.9 Satisfied (50 Votes)
2013	4.2 Satisfied (59 Votes)

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We have answers to the most popular questions from our customers. If you can't find an answer to your question, please contact us.

What is my last 4 digits of SSN?

No valid SSN has 9 identical digits or has the 9 digits running consecutively from 1-9. For example, all of the following SSNs are invalid: 111-11-1111. 999-99-9999.

How do I find the last 4 digits of my SSN?

The last four digits are commonly used by organizations and businesses for verification purposes. They may be used to confirm a persons identity in financial transactions, employment processes, and other situations requiring identity verification.

Are the last 4 digits of SSN public?

Footnote: It is true that the application form for an SSN asks for identfying information, such as date of birth, place of birth, parents names, and (optionally) the applicants race. But none of this identifying information is encoded in the SSN itself--not the persons date of birth, place of birth, or race.

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