Fillable Information from an Audio Recording Request to Erase (Colorado DORA)

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Information from an Audio Recording Request to Erase (Colorado DORA)

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1
Instructions for Completing the
Request to Erase (Redact) Medical
Information from an Audio Recording
Please read all pages
This form is “fillable.” That means you can type the information onto
the form from your computer and print the form. You will not be able
to save the form onto your computer’s hard drive.
When you open the form, click in the “Claimant” box (field), complete
the information, and use the tab key to navigate to the next field. Do
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Request to Erase (Redact) Medical Information from an Audio Recording
To: Colorado Division of Workers’ Compensation W.C. No:
Attn: Customer Service Unit
633 17
th
Street, Suite 400
Denver, CO 80202-3626
From:
Claimant name
Address:
Insurer/ Employer: Claim No:
I, the injured worker, recently had an independent medical examination. I have received and listened to a
copy of the audio recording of that examination. During the examination I made statements concerning a
medical condition that I believe should remain private because the condition is not connected to my workers’
compensation claim. I am asking that the part(s) of the recording that contain this information be erased from
the recording.
In order for this request to be considered I must describe, in general, the medical information I believe was
private. I am not asking that any information included in the written report be erased. Since I believe this
information is private I do not want to provide too much detail, but I understand I must provide enough
information that a judge can find the discussion on the recording and decide whether it should remain private.
The information is not relevant to my workers’ compensation claim, and I am formally requesting that this
information be redacted (erased) from the audio recording.
The information is contained in the recording at time marker:______________________ (if available)
The following is a general description of information that I request be deleted from the recording:
Signature
I am providing this form to the Division of Workers’ Compensation along with a copy of the audio recording
and a copy of the written medical report. I understand that I must send a copy of just this completed form to
the doctor that examined me and to the adjuster or the insurer’s attorney handling my claim.
CERTIFICATE OF SERVICE: Copies of this document were placed in the U.S. Mail or hand-delivered to
the following parties this ___________of _______________, ___________.
List the names and addresses of all the persons copied:
Insurer/ Employer:
Examining Physician:
By:
Signature
WC34 08/09
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Information from an Audio Recording Request to Erase (Colorado DORA)

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Completed 27 January 2021

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