Claimant’s Authorization to Disclose Workers’ Compensation Information - Form OC-110A

Sep 17, 2026

Uploaded by Liam

Claimant’s Authorization to Disclose Workers’ Compensation Information is a form used to allow the Workers’ Compensation Board to discuss specified case(s) and release records to named parties. Claimants must complete all required fields and provide SSN or ITIN where requested, and requests with incomplete entries or missing witness information are not processed. The authorization is effective until revoked in writing and does not create a records request; records copies require Form OC-RR.

LanguageEnglish

CategoryForms

FormatPDF

Pages2

Reading Time1 min

AccessFree to download

Claimant Authorization Overview

Completion Requirements and Processing Notes

Effectiveness, Revocation, and Limitations

Claimant and Case Information

Claimant Details

Case Number(s) and Accident Date(s)

Parties Receiving Records

Party Details and Initials

Signatures and Witness Information

Claimant/Authorized Representative Signature

Witness Signature, Name, and Address

Submitting the Document

Mail

Web Upload

Claimant’s Authorization to Disclose Workers’ Compensation Information (Pursuant to Workers’ Compensation Law § 110-a) See important information on reverse before completing this form Claimants are prohibited from authorizing release of workers' compensation information to prospective employers or in connection with assessing fitness or capability for employment. Please complete all items. An incomplete or illegible form will delay the processing of your request. If you are requesting case copies, please include completed Form OC-RR indicating the requested materials. Case copies are sent via secure email. Be sure to include your email address. | Claimant’s Name: | Claimant’s SSN or ITIN: | Case Type(s): WC: DB: | | Discrimination: PFL: | | --- | --- | --- | --- | --- | | | | | | | | Case Number(s) and/or Date(s) of Accident (list all for which records are being requested): | | | | | To submit this document, read the “Methods for submitting this document” on the reverse page. Authorization for disclosure of records for certain purposes is not valid under the law. See excerpt of WCL § 110-a on the reverse of this form. This authorization is effective until it is revoked by the claimant. The claimant may revoke this authorization at any time upon written notice to the Workers’ Compensation Board. This authorization does not permit the authorized party to open an individual eCase account or to view cases via eCase outside of a Board location. This authorization does not generate a records request. Use form OC-RR to initiate a records request. Note that when a party uses any third-party agent, such as a copy service, all parties to receive records must be listed individually and initialed by the claimant. The requesting party may be required to pay a statutory fee prior to being provided copies of these records. The claimant must initial for each party who will receive records. Parties may not be added to this authorization after the authorization is signed. I authorize the Workers’ Compensation Board to discuss the above-referenced Workers’ Compensation Board case(s) with and/or release a copy of the above-referenced case(s) records to the following parties: | Party
1 | Initial: | Party Name: | Email: | | --- | --- | --- | --- | | | Mailing Address: | | | | Party
2 | Initial: | Party Name: | Email: | | | Mailing Address: | | | Limitations on release: This form must be signed by the claimant (or the claimant’s authorized representative) and personally witnessed. An authorized representative may be a legal guardian for an incapacitated injured worker, an estate administrator or executor for a deceased injured worker, or a person with valid Power of Attorney. Any Power of Attorney form must specifically allow release of legal records; authorization under HIPAA or NY Public Health Law is insufficient. Claimant’s Signature (or Authorized Representative) Date Authorized Representative (documentation included) The witness’s name and address must be completed. Requests with blank or incomplete witness fields will not be processed. I affirm that I witnessed the claimant or an authorized representative of the claimant personally sign this form. Witness’s Signature Date Witness’s Name Witness’s Address Failure to provide the SSN or ITIN 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 SSN or ITIN enables the Board to ensure that information is associated with, and quick action is taken on, your request. Methods For Submitting This Document: | Email | Mail | Web Upload | | --- | --- | --- | | [wcbclaimsfiling@wcb.ny.gov](wcbclaimsfiling@wcb.ny.gov) | NYS Workers’ Compensation Board Centralized Mailing Address
PO Box 5205
Binghamton, NY 13902-5205 | [https://wcbdoc.services.conduent.com/](https://wcbdoc.services.conduent.com/) | | | | | Purpose of This Form: Confi

FAQs

Who is allowed to receive workers’ compensation records under this authorization?

Only the specific parties listed on the form (with the claimant’s initials) are authorized to receive the referenced case records. Parties cannot be added after the form is signed.

Does submitting this form automatically generate a request for records copies?

No. This authorization does not generate a records request. Those seeking copies must submit Form OC-RR to initiate the records request.

How long is the authorization valid and how can it be revoked?

The authorization is effective until it is revoked by the claimant. Revocation must be submitted in writing and there is no specific required format, including revocation by email.

Sep 17, 2026

Uploaded by Liam