I hereby authorize any physician, hospital, pharmacy, or medically related facility, insurance company, employer or other person or other organization, institution or person, that has any records or knowledge of me to disclose, whenever requested to do so by my employer or Providence Risk & Insurance Services, Inc. or it’s representative, any and all such information. A photocopy of this authorization shall be considered as effective and valid as the original.

By my signature, I hereby acknowledge that I know it is a crime to complete this form with information I know is false or to omit any facts that might be pertinent to this claim. I certify that the above information is correct and that I have completed this form truthfully without any coercion from my employer.

I agree that should this Injury or Illness result from the actions of a third party, that unless otherwise stipulated by the Plan, I will repay to the Plan all amounts paid by the Plan in connection with this Injury or Illness upon recovery of any amounts.