AUTHORIZATION FOR RELEASE OF WAGE LOSS INFORMATION I AUTHORIZE

  AUTHORIZATION AND CONSENT FOR DISCLOSURE OF CRIMINAL
6 ARTICLE 6B INTERIM CASINO AUTHORIZATION 5129512
CAPITAL EXPRESS INTERNET BANKING FOR BUSINESS CLIENT AUTHORIZATION

INFORMED CONSENT FORM AND HIPAA AUTHORIZATION STUDY
INSTITUTIONAL REVIEW BOARD AUTHORIZATION FOR USE OF PROTECTED
325 MHZ TEST AREA QUALIFICATION AND AUTHORIZATION RECORD LAST

AUTHORIZATION FOR RELEASE OF WAGE LOSS INFORMATION

AUTHORIZATION FOR RELEASE OF WAGE LOSS INFORMATION



I authorize my employer(s): _____________________________________


__________________________________________________


___________________________________________________


To release information concerning my wages and salaries while employed by the above-referenced employer(s). You are authorized to provide this information to:


AAA Insurance Co

P O Box 1111

Tampa, Fl 11111


-------------------------------------------------------------------




Dates of Employment: ________________ to _________________


Hourly Wage: $_______________


Dates Absent from Work: ________________ to _________________


Calculated Wage Loss: $____________________________________




_________________________

EMPLOYEE SIGNATURE DATE




__________________________

PRINT EMPLOYEE NAME EMPLOYEE

SOCIAL SECURITY NUMBER




Any person who knowingly and with intent to injure, defraud, or deceive any insurance company, files a statement of claim containing any false, incomplete or misleading information is guilty of a felony of the third degree.



/var/www/doc4pdf.com/temp/85168.doc


ACCOUNT NAME DATE BARKER LSA STOCKROOM SIGNATURE AUTHORIZATION
ACCOUNTS PAYABLE STUDENT DIRECT DEPOSIT AUTHORIZATION FORM STUDENT NAME
ADMISSION AUTHORIZATION – SPECIALIZED CARELONG STAY ACUTE CARE HOSPITALS


Tags: authorization for, authorize, authorization, information, release