* NOTE: This form is in Adobe Acrobat format. You must have the free Adobe Acrobat Reader to access the form.
Immediately after sustaining a work-related injury, the claimant should fill out this release form. This enables SORM to obtain from providers copies of relevant medical documents that will assist in the handling of the claim.
The form must be received by SORM not later than the 5th calendar day after the first notice of injury is reported to the agency.
The employee must complete this form. If the employee is incapacitated, the spouse, child, or legal guardian can sign the form. THE FORM MUST BE SIGNED AND DATED. The claims coordinator should make this form available.
- The claimant must clearly print his or her name on the patient line.
- The claimant must clearly print his or her name on the second line.
- The claimant must date and sign the form.
Fax a copy or mail the original to:
State Office of Risk Management
The claimant should retain a personal copy.