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The OC 110A form, officially known as the Claimant's Authorization to Disclose Workers' Compensation Records, plays a vital role in the New York workers' compensation system. It serves as a formal request that allows claimants—those who have filed for workers' compensation benefits—to authorize the release of their records to specific individuals or entities. This form is strictly regulated under Workers' Compensation Law Section 110-a, which outlines that claimants cannot authorize these records to be shared with prospective employers or for employment fitness assessments. The form requires key information, including the claimant's name, Social Security number, and details about the related case. Importantly, the authorization remains valid until the claimant decides to revoke it. There are significant instructions regarding submission and recordkeeping, emphasizing that incomplete forms can result in delays. Claimants are also informed that they might need to pay a fee for the retrieval of these records. By ensuring all sections are accurately filled out, this straightforward form can expedite processing, helping to maintain the integrity of sensitive workers' compensation information while allowing for necessary disclosures.

Oc 110A Example

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 WCB DB Discrimination PFL and/or Date of Accident

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

Get Oc 110A PDF Form

Form Characteristics

Fact Name Details
Purpose The OC-110A form is used to authorize the disclosure of workers' compensation records.
Governing Law This form is governed by Workers' Compensation Law Section 110-a.
Prohibited Releases Claimants cannot authorize the release of records to prospective employers or for employment fitness assessments.
Effectiveness The authorization remains valid until revoked by the claimant.
Submission Instructions The original must be submitted to the Workers' Compensation Board, and claimants should keep a copy.
Social Security Number Providing a social security number helps expedite processing but is not mandatory.
Revocation Claimants may revoke the authorization at any time with written notice to the Workers' Compensation Board.
Signature Requirement The form must be signed in ink, preferably blue, by the claimant.
Legal Consequences Unauthorized disclosure of records may result in criminal charges and civil penalties.

Guidelines on Utilizing Oc 110A

Filling out the OC-110A form correctly is crucial, as missing information can delay your request. This form authorizes the Workers' Compensation Board to disclose your workers' compensation records to a designated person or entity. It is important to follow the steps carefully to ensure your information is processed smoothly.

  1. Begin by writing your Claimant's Name in the designated space at the top of the form.
  2. Next, provide your Social Security or Tax Identification Number in the appropriate box.
  3. Fill in your Case Number, ensuring accuracy to avoid any issues with identification.
  4. Indicate whether the case relates to WCB, DB, Discrimination, or PFL as relevant.
  5. Include the Date of Accident as noted in your records.
  6. If necessary, identify any other case files by providing their WCB/DB/DC/PFL Case Numbers and/or their respective Dates of Accident.
  7. Authorize the release of records by writing the name of the person or entity to whom the information will be disclosed.
  8. Complete the Address field for the person or entity receiving the records.
  9. Sign your name on the line labeled Claimant's Signature, using ink only. If possible, use blue ink.
  10. Finally, date the form adjacent to your signature.

After you complete the form, submit the original to the Workers' Compensation Board and keep a copy for your records. Ensure that the form is filled out completely to prevent any unnecessary delays.

What You Should Know About This Form

What is the purpose of the OC 110A form?

The OC 110A form serves as a claimant's authorization to disclose workers' compensation records. This authorization is specifically outlined under Section 110-a of the Workers' Compensation Law. It allows claimants to permit the Workers' Compensation Board to share their records with a designated individual or organization, provided that the recipient is identified on the form.

Who can I authorize to receive my workers' compensation records?

You can authorize any specific person, corporation, association, or entity to receive your records. However, it’s important to note that this authorization cannot be used for prospective employers or for assessing fitness for employment. The specific recipient must be mentioned, along with their address, on the OC 110A form.

Can I revoke the authorization once I complete the OC 110A form?

Yes, you may revoke the authorization at any time. To do so, simply provide a written notice to the Workers' Compensation Board. Once revoked, the earlier authorization will no longer be valid.

What should I do if I don't have all the information to complete the OC 110A form?

While missing information won't lead to the denial of your authorization, it could delay the processing of your request. It's crucial to provide as much detail as possible to ensure timely processing. If you're unsure about certain items, consider reaching out to the Workers' Compensation Board for assistance.

Where do I submit the OC 110A form once it's completed?

You should send the original OC 110A form to the Workers' Compensation Board at the designated PO Box provided on the form. It's advisable to keep a copy for your personal records as well.

Is there a fee associated with obtaining my records?

Yes, the entity requesting your records may be required to pay a statutory fee to the Workers' Compensation Board before receiving copies of the records. This fee typically covers the administrative costs of processing the request.

What happens if I fail to provide my Social Security number on the form?

While providing your Social Security number is voluntary, it helps the Workers' Compensation Board ensure that your information is matched correctly and assists in speeding up the processing of your request. Failure to provide it will not prevent you from authorizing record release, but it may lead to delays.

What are the legal implications of disclosing my workers' compensation records?

The law places strict limitations on the disclosure of workers' compensation records. Unauthorized disclosure may result in penalties, including fines or criminal charges. Thus, ensure that you understand and adhere to the rules surrounding record release to avoid any legal issues.

Common mistakes

Filling out the OC 110A form can be straightforward, but mistakes often occur that can lead to delays in processing. One common mistake is not providing complete information. Each section of the form must be filled out completely, including the claimant's name, social security number, and case number. When any information is missing, the Workers' Compensation Board may not be able to process the request, thus extending the time it takes to obtain the records.

Another frequent error is failing to sign the form appropriately. The instructions clearly state that the claimant's signature must be in ink, preferably blue ink. Some individuals overlook this detail and opt for a digital signature or fail to sign altogether. Without the proper signature, the authorization cannot be validated, leading to further complications.

Also, individuals sometimes misunderstand the restrictions regarding the release of information. The OC 110A form explicitly prohibits the authorization of workers' compensation information to prospective employers or for assessing fitness for employment. Misinterpreting this can result in submitting an invalid request, which would be rejected outright.

Lastly, another common misstep involves not retaining a copy of the completed form. It is advised to keep a personal copy for your records after submission. Some people neglect this step, which can be problematic if there are questions or issues regarding the request later. Having a copy of the signed form ensures that the claimant has documentation of what was submitted, facilitating communication with the Board if necessary.

Documents used along the form

When dealing with workers' compensation claims, several forms and documents may accompany the OC 110A form. Each of these documents serves a specific purpose and can help ensure that the process is smooth and compliant with the law. Here’s a brief overview of the most commonly used forms:

  • WCB Form C-3: This form is used to report the details of a work-related injury or illness to the Workers’ Compensation Board. It serves as an official notice of the claim and is crucial for initiating the compensatory process.
  • WCB Form C-4: The C-4 form is a medical report that must be completed by the claimant’s healthcare provider. It outlines the diagnosis, treatment received, and prognosis, helping to establish the severity of the injury.
  • WCB Form C-7: This document is a notice of controversy form that allows one party to contest the workers' compensation claim. It can be filed by either the employer or the claimant, indicating disagreement regarding the claim's validity.
  • WCB Form C-27: A request for a hearing is made using this form. It is typically submitted if the claimant or employer disagrees with a decision made by the Workers’ Compensation Board, seeking resolution through formal proceedings.
  • WCB Form C-8: This is an application for the review of an initial denial of a claim. By filing this form, the claimant asks the Board to re-evaluate the decision based on additional evidence or circumstances.
  • WCB Form C-851: This form is utilized for voluntary withdrawal from workers' compensation claims. It is essential when a claimant wishes to retract their claim and the associated benefits.
  • WCB Form C-45: This form reports the payment of wages to an injured worker during their recovery period. It provides essential documentation for the compensation process, ensuring that the claimant receives appropriate wage benefits.
  • WCB Form C-73: This is a notice of claim form that can be submitted by family members in the event of a work-related death. It sets the foundation for survivor benefits and other compensation related to the loss.
  • WCB Form C-69: The final form is generally a notice of change of condition. It allows the claimant to inform the Workers' Compensation Board about any significant changes in their medical condition affecting their benefits.

Each of these documents plays a pivotal role in the workers' compensation process, ensuring that claims are managed effectively and that claimants receive the support they need. Understanding the function of these forms can help navigate the often-complex landscape of workers' compensation claims.

Similar forms

The OC 110A form, which is an authorization for claimants to disclose workers' compensation records, shares similarities with several other forms related to the release of personal information and benefits. Here are seven documents that are comparable to the OC 110A form and an explanation of how they are similar:

  • HIPAA Authorization Form: This document allows individuals to authorize the release of their health records to specific parties. Like the OC 110A, it requires the claimant's consent for disclosure, ensuring that sensitive information is shared appropriately.
  • Authorization for Release of Educational Records: Under the Family Educational Rights and Privacy Act (FERPA), this form permits students to authorize the release of their educational records. Similar to the OC 110A, it emphasizes the importance of consent and the specific identification of the individuals receiving the information.
  • General Release Form: This document allows individuals to waive their right to pursue claims against a party in exchange for compensation. Both forms require the individual's signature and provide clear instructions about who can receive the information or funds involved.
  • Social Security Administration Authorization to Disclose Information: This form enables individuals to grant permission for the SSA to share their records with particular entities, mirroring the consent aspect of the OC 110A regarding the release of personal information.
  • Insurance Claim Authorization Form: Often required in medical insurance claims, this form permits healthcare providers to disclose medical records to insurance companies. Like the OC 110A, it ensures that individuals are aware of and agree to the release of their sensitive information.
  • Power of Attorney Document: This legal document allows individuals to appoint someone to act on their behalf, including the authorization to disclose personal information. The OC 110A form has a similar structure in that it centers around the claimant's ability to give consent to share their records.
  • Workers' Compensation Release of Information Form: This form is specifically designed for workers' compensation cases, allowing an individual to authorize the release of their records to designated parties. It shares the same purpose and procedural requirements as the OC 110A form, focusing on the claimant’s control over their case information.

Overall, each of these documents emphasizes the importance of individual consent in the release of personal or sensitive information, while also providing clarity on who is authorized to receive that information.

Dos and Don'ts

When filling out the OC 110A form, follow these important guidelines to ensure your application is processed efficiently.

  • Do provide your full name clearly as it appears on your identification.
  • Do include your Social Security Number or Tax Identification Number to avoid processing delays.
  • Do write the date of the accident accurately, as it is crucial for linking your record.
  • Do authorize the release of records to a specific person or entity only if it complies with the law.
  • Do sign the form in blue ink to ensure clarity and authenticity.
  • Don't authorize the release of your workers' compensation information to prospective employers.
  • Don't leave any sections of the form blank; incomplete forms will delay your request.
  • Don't attempt to open an individual eCase account; this form does not allow for such actions.
  • Don't use black ink when signing; blue ink is preferred for a clear signature.

Following these guidelines will facilitate a smoother processing experience for your OC 110A form.

Misconceptions

Misconceptions about the OC-110A form can lead to confusion. Here are eight common misunderstandings clarified:

  • Claimants can authorize their information for employment purposes. This is incorrect. The form explicitly prohibits releasing workers' compensation information to prospective employers.
  • Incomplete forms are automatically denied. While processing may be delayed, failure to provide all information does not result in denial of the authorization.
  • Claimants must authorize record releases for all entities. Not true. The authorization must specify the individual or entity receiving the information, and it cannot be general.
  • A claimant’s social security number is mandatory. While providing it aids processing, it is voluntary and not required for authorization to be valid.
  • Claimants can access their workers' compensation records using the OC-110A form. This form does not grant access to individual eCase accounts or case viewing outside Board locations.
  • Authorized persons can disclose the information freely. Any individual who receives this information cannot share it with anyone unless they are also authorized to receive it.
  • Revoking authorization is complicated. In reality, claimants can revoke their authorization at any time by providing written notice to the Workers' Compensation Board.
  • Submitting the authorization form electronically is allowed. Claimants must submit the original form; electronic submissions cannot replace that requirement.

Key takeaways

Utilizing the OC-110A form effectively is crucial for claimants wanting to manage their workers' compensation records. Here are several important points to consider:

  • Complete All Required Information: Ensure that every item on the form is filled out completely. An incomplete form can lead to delays in processing.
  • Authorization Limits: The form cannot be used to authorize the release of records to prospective employers or for assessing employment fitness. These restrictions are mandated by law.
  • Revocation of Authorization: Claimants can revoke their authorization at any time by providing written notice to the Workers' Compensation Board. This means that control over released information is retained.
  • Submission Process: Submit the original form to the Workers' Compensation Board and keep a copy for personal records. This practice helps ensure that you have proof of your request.

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