Office of Workers Compensation Programs
P.O. Box 8300 District #
London, Ky 40742-8300
RE: Your Name
Date of Injury:
PRIVACY ACT REQUEST
In addition, I also request a complete accounting of disclosures on the above referenced claim.
Replace the items in Red with your information. Remember to keep a copy for your records.
I also request a copy of Physician's Name completed second opinion or IME report be sent to me upon receipt by the Office.1. The Statement of Accepted Facts, (SOAF) the Office will be sending Physician's Name;2. The questions the Office is posing to Physician's Name; and3. Any X-Ray films or other diagnostic test results the physician performs during the examination.
Your Phone Number
HOW TO...REVOKE A MEDICAL RELEASE
As always, replace the items in Red with your information. Write Privacy Act Request on the outside of your envelope and remember to keep a copy for your records.
Office of Workers' Compensation Programs
P.O. Box 8300 District #:
London, KY 40742
Re: Your Name:
Your Claim Number:
Your Date of Injury: