I hereby further authorize the above persons or organizations, any physician, medical practitioner, hospital, clinic, other medical or medically related facility, pharmacy, insurer, claims administrator, and my employer(s) to disclose or furnish to Sedgwick, my employer, or any of their authorized representatives, all facts concerning my medical condition and disability (including physical, mental health, alcohol, substance abuse and HIV related information), wages or earnings, that are within their knowledge and to allow inspection of and provide copies of any medical records (including diagnosis, prognosis, prescriptions or medication, psychiatric, drug or alcohol abuse treatment).

I hereby authorize the use or disclosure of my personal health information upon request by Sedgwick from all claim processors appointed by my employer, including but not limited to those who administer my employer’s Group Health, Short-Term Disability, Long-Term Disability, Workers’ Compensation and Employee Assistance Program (EAP). I certify all of the information above is to the best of my knowledge true, correct and complete.

Sedgwick only needs one copy of this form, so please choose one method of delivery only.ĬERTIFICATION AND AUTHORIZATION FOR RELEASE OF INFORMATION STEP 2: Sign and return this form by FAX TO (818) 591-7664 OR by mail to Sedgwick, P.O. NOTE: Your Sedgwick claim number is mandatory for identification purposes.

Landlord (Tenant) Recommendation Letter.

Return to work form sedgwick