Workers’ Compensation Forms-Authorization to Disclose Workers’ Compensation Records (110A)
Completing this form authorizes the disclosure of your Workers’ Compensation records.To complete this form, follow these instructions: • Fill in your name. • Select which case type the records are being used for, including Workers’ Compensation, Disability, or Discrimination. • Fill in your full Social Security Number and date of accident (your Social Security Number is not saved on this website). • The form defaults to sending the records to our law firm. • Click “Generate 110A.” The form will be generated as a PDF to your computer. A letter of transmittal will also be created. • Print the documents. • Sign and date on the bottom line in BLUE INK of the form, if possible. • Mail in the document and the transmittal letter.
Please Be Aware: This form does NOT create an attorney-client relationship. Rather, the Claimant’s Authorization to Disclose Workers Compensation Records merely allows Meggesto, Crossett & Valerino, LLP. MCV Law to review the Electronic Case Folder (ECF) maintained by the NYS Workers Compensation Board. MCV Law uses this form to evaluate your case.
Claimant’s Authorization to Disclose Workers’ Compensation Records
