Employment Records Authorization

Employment Records Authorization

Before you use this: Identify one record holder and the minimum records needed for the stated matter. Use the holder's required form or a court order where necessary. Keep medical, benefits, tax-return, bank and third-party records on separately reviewed authorizations.

Person authorizing disclosure: [EMPLOYEE FULL LEGAL NAME]

Other identifier used by employer, if necessary: [EMPLOYEE NUMBER OR LAST FOUR DIGITS ONLY]

Contact for identity confirmation: [PHONE OR SECURE ADDRESS]

Employer or record holder authorized to disclose: [LEGAL NAME, HR/PAYROLL CONTACT, ADDRESS]

Employment period relevant to request: [START DATE] through [END DATE]

Recipient authorized to receive records: [ATTORNEY/FIRM OR OTHER PERSON, ADDRESS, SECURE EMAIL OR PORTAL]

Matter and purpose: Records are requested to document [MISSED WORK, WAGE HISTORY, EARNING CAPACITY, OR OTHER PRECISE ISSUE] in [IDENTIFIED CLAIM OR MATTER AND DATE]. This authorization is limited to that purpose and the categories selected below.

Records authorized

Excluded unless separately authorized: personnel discipline, medical or accommodation records, health and disability benefits, complete tax returns, bank records, Social Security number, and records of other employers. This authorization does not ask the employer to conclude that any absence was caused by an injury; the employer may report its own contemporaneous records and observations.

The record holder may send the selected records to the recipient above by [SECURE METHOD] and may confirm [SPECIFIC FACTS] with [NAMED CONTACT] by [METHOD]. No onward disclosure is authorized by this document beyond the identified matter; later use or compelled production is governed by the applicable agreement, law, and order.

Expiration: This authorization ends on [__/__/____] or upon [CLEAR EARLIER EVENT], whichever occurs first. A new signed authorization is needed for a broader scope or later period.

Revocation instructions: I may send a written revocation to [EMPLOYER CONTACT AND ADDRESS] and a copy to [RECIPIENT CONTACT]. The record holder should stop future voluntary disclosures after receiving it, subject to any separate legal duty or prior completed disclosure. The date and method of notice will be recorded by the sender.

I have read the specific categories, period, recipient, purpose, expiration, and revocation route above. I authorize the record holder to release only the selected information, subject to applicable law and its identity-verification procedure. I may request a copy of this signed authorization from [CONTACT].

Employee signature: ______________________________ Date: [__/__/____]

Printed name: [EMPLOYEE NAME]

Authorized representative, if the employee cannot sign: [NAME, ROLE, AUTHORITY DOCUMENT, SIGNATURE, DATE]

Delivery record: Sent to [RECORD HOLDER] on [__/__/____] by [METHOD]; reference [TRACKING OR RECEIPT].