Fillable Oc110a Printing T:\\AAOSHARE\\FINLFORM\\OC110A.FRP

Fill Online, Printable, Fillable, Blank Oc110a Printing T:\\AAOSHARE\\FINLFORM\\OC110A.FRP Form

Use Fill to complete blank online NEW YORK STATE pdf forms for free. Once completed you can sign your fillable form or send for signing. All forms are printable and downloadable.

Oc110a Printing T:\\AAOSHARE\\FINLFORM\\OC110A.FRP

On average this form takes 3 minutes to complete

The Oc110a Printing T:\\AAOSHARE\\FINLFORM\\OC110A.FRP form is 1 page long and contains:

  • 0 signatures
  • 4 check-boxes
  • 10 other fields

Country of origin: US
File type: PDF

Free fillable forms for New York State

BROWSE NEW YORK STATE FORMS

Related forms
Fill has a huge library of thousands of forms all set up to be filled in easily and signed.
Fill in your chosen form
Sign the form using our drawing tool
Send to someone else to fill in and sign.
find another form
 
CLAIMANT'S AUTHORIZATION TO DISCLOSE
WORKERS' COMPENSATION RECORDS
(Pursuant to Workers' Compensation Law Section 110-a)
PO Box 5205, Binghamton, NY 13902-5205 l www.wcb.ny.gov
CLAIMANTS ARE PROHIBITED FROM AUTHORIZING RELEASE OF WORKERS' COMPENSATION INFORMATION TO
PROSPECTIVE EMPLOYERS OR IN CONNECTION WITH ASSESSING FITNESS OR CAPABILITY OF EMPLOYMENT.
PLEASE COMPLETE ALL ITEMS. AN INCOMPLETE FORM WILL DELAY THE PROCESSING OF YOUR REQUEST.
Claimant's Name
Claimant's Social Security
or Tax Identification Number
Case Number
and/or Date of Accident
WCB Discrimination PFLDB
IF RELEASE IS AUTHORIZED FOR ADDITIONAL CASE FILE(S), IDENTIFY BELOW BY WCB/DB/DC/PFL CASE NUMBER AND/OR DATE OF
ACCIDENT(S)
INSTRUCTIONS:
Submit original to the Workers' Compensation Board and retain a copy for your records. Authorization for disclosure of
records for certain purposes is not valid under the law. See excerpt of WCL Section 110-a on the reverse of this form. This
authorization is effective until it is revoked by the claimant. Claimant may revoke this authorization at any time upon
written notice to the Workers' Compensation Board.
THIS AUTHORIZATION DOES NOT PERMIT YOU TO OPEN AN INDIVIDUAL eCASE ACCOUNT
OR TO VIEW CASES VIA eCASE OUTSIDE OF A BOARD LOCATION.
Pursuant to Section 110-a of the Workers' Compensation Law, I,
,
(CLAIMANT'S NAME)
represent that I am a person who is/was the subject of the workers' compensation cases(s) indicated above, and I authorize the
Workers' Compensation Board to discuss the above-referenced Workers' Compensation Board records with and/or release a copy of
the above-referenced records to
,
(NAME OF A SPECIFIC PERSON, CORPORATION, ASSOCIATION OR PUBLIC OR PRIVATE ENTITY)
at
(ADDRESS)
.
I understand that the requesting party may be required to pay a statutory fee prior to being provided copies of these records by the
Workers' Compensation Board.
Claimant's Signature (ink only - use blue ink if possible)
Date
Failure to provide the information requested on this form will not result in the denial of your authorization, but may delay the
processing of your request. The voluntary release of your social security number enables the Board to ensure that
information is associated with, and quick action is taken on, your request.
OC-110A (12-17)
Prescribed by the Chair, Workers' Compensation Board
OC-110A 12-17
Pursuant to Workers' Compensation Law Section 110-a:
3. Individual authorization. Notwithstanding the restrictions on disclosure set forth under subdivision one of this section, a
person who is the subject of a workers' compensation record may authorize the release, re-release or publication of his or
her record to a specific person not otherwise authorized to receive such record, by submitting written authorization for such
release to the board on a form prescribed by the chair or by a notarized original authorization specifically directing the
board to release workers' compensation records to such person. However, in accordance with section one-hundred twenty-
five of this article, no such authorization directing disclosure of records to a prospective employer shall be valid; nor shall
an authorization permitting disclosure of records in connection with assessing fitness or capability for employment be valid,
and no disclosure of records shall be made pursuant thereto. It shall be unlawful for any person to consider for the purpose
of assessing eligibility for a benefit, or as the basis for an employment-related action, an individual's failure to provide
authorization under this subdivision.
4. It shall be unlawful for any person who has obtained copies of board records or individually identifiable information from
board records to disclose such information to any person who is not otherwise lawfully entitled to obtain these records.
5. Any person who knowingly and willfully obtains workers' compensation records which contain individually identifiable
information under false pretenses or otherwise violates this section shall be guilty of a class A misdemeanor and shall be
subject upon conviction, to a fine of not more than one thousand dollars.
6. In addition to or in lieu of any criminal proceeding available under this section, whenever there shall be a violation of this
section, application may be made by the attorney general in the name of the people of the state of New York to a court or
justice having jurisdiction by a special proceeding to issue an injunction, and upon notice to the defendant of not less than
five days, to enjoin and restrain the continuance of such violations; and if it shall appear to the satisfaction of the court or
justice that the defendant has, in fact, violated this section, an injunction may be issued by such court or justice, enjoining
and restraining any further violation, without requiring proof that any person has, in fact, been injured or damaged thereby.
In any such proceeding, the court may make allowances to the attorney general as provided in paragraph six of subdivision
(a) of section eighty-three hundred three of the civil practice law and rules, and direct restitution. Whenever the court shall
determine that a violation of this section has occurred, the court may impose a civil penalty of not more than five hundred
dollars for the first violation, and not more than one thousand dollars for the second or subsequent violation within a three
year period. In connection with any such proposed application, the attorney general is authorized to take proof and make a
determination of the relevant facts and to issue subpoenas in accordance with the civil practice law and rules.
OC-110A (12-17) REVERSE
Prescribed by the Chair, Workers' Compensation Board
Download
Save PDF to desktop
Email
Email completed PDF
Send for Signing
Email for others to sign
Print
Print document
Choose a Field
Click on a field and
select the person that should complete it
Want to add a signature?
You can add a signature field
and assign it to someone else
to sign
Choose a Field
Click on a field and
select the person that should complete it

Oc110a Printing T:AAOSHAREFINLFORMOC110A.FRP

This document is locked as it has been sent for signing.

You have successfully completed this document.

Other parties need to complete fields in the document. You will recieve an email notification when the document has been completed by all parties.

This document has been signed by all parties.

Completed 13 May 2020

Message

View Audit Log
Print With Audit Log
Duplicate Document