FORM: Authorization to obtain and release information

Submitting this form gives WCAT permission to obtain information about you (the worker) relating to an appeal currently being heard at WCAT. The information WCAT obtains will be released to other parties or participants in the appeal.

Questions marked (Required) must be filled in.

Collection and use of personal information: Personal information on this form is collected for the processing and adjudication of a WCAT matter under the Workers Compensation Act and the Freedom of Information and Protection of Privacy Act. Contact the Freedom of Information Coordinator at WCAT if you have questions.

1. Identify the appeal

The appeal was started by (appellant’s name): (Required)

Appeal number (Required)

2. Information about you (the worker)

Your name (Required)

First Last

Your pronouns and title

Your pronouns and title will help us to address you respectfully during the appeal process. If you choose “not listed”, a new field will open where you can tell us your pronouns and/or title.

You are free to skip these questions. If there is information about your gender in the WorkSafeBC or Review Division file(s), we will use that when choosing how to address you.

Your pronouns

They/Them
She/Her
He/Him
Pronouns not listed

Your pronouns (Required)

Please tell us your pronouns.

Your title

Your title (Required)

Please tell us how you would like to be addressed.

Your birth date (Required)

Your mailing address (Required)

Street address Address line 2 City Province / State / Region Postal / Zip Code Country

Your phone (daytime) (Required)

Your phone (other)

Your fax

3. Certification and authorization

The worker—not the worker’s representative—must sign this form.

Full name of person signing this form (Required)

I understand that checking this box constitutes a legal signature confirming that I acknowledge and agree to the following: (Required)

I authorize disclosure of my WorkSafeBC file(s) and information relating to this appeal to WCAT, my representative, and other parties to this appeal for the purposes of this appeal and as allowed under section 314 of the Workers Compensation Act. I also authorize WCAT to obtain or view a copy of my medical and employment records from any source, including physicians, health practitioners, medical insurers, hospitals and employees.

Date signed

Email address for form confirmation

Enter an email address here if you would like to receive confirmation that WCAT received your form. WCAT will send you a copy of the completed form by mail or email (depending on your preferences as shown on the notice of appeal or participation form).

Enter email Confirm email

Comments

This field is for validation purposes and should be left unchanged.

Authorization to obtain and release worker information

1. Identify the appeal

2. Information about you (the worker)

3. Certification and authorization