Get Missouri Authorization To Release Information (wc-126-ai)

Completing the Missouri Authorization To Release Information (WC-126-AI) online allows employers and employees to efficiently obtain necessary workers’ compensation records. This guide will walk you through each section of the form step by step, ensuring you understand what information is required and how to submit the form correctly.

Follow the steps to fill out the form accurately and effectively.

1. Click 'Get Form' button to access the Missouri Authorization To Release Information (WC-126-AI) form in an editable format.
2. Fill in the employer's information in the designated section. This includes the employer's full name, Federal Employer Identification Number (FEIN), street address, city, state, and zip code. Ensure all information is clear and correctly spelled.
3. The employer must sign and date the authorization statement affirming that the request is for job-related purposes and will comply with the Americans with Disabilities Act. This signature must be accompanied by the date on which it was signed.
4. Next, move to the employee section. The employee must confirm their status as either a current employee or an individual who has received a conditional job offer by signing and dating the form. The signature must be different from that of the employer.
5. Complete the employee's details including their full name, Social Security Number, street address, city, state, and zip code. Make sure the Social Security Number is legibly written.
6. The employee’s signature must be notarized. Ensure the notary public's signature, seal, and details are clearly marked on the document, indicating the date this occurred.
7. Prepare a self-addressed, stamped envelope that will be used to return the requested information to the employee.
8. Include the records search fee of $5.00 per individual, submitting either a company check or money order made out to the Division of Workers’ Compensation, as cash is not accepted.
9. Once all information is filled out and fees are included, review the entire form for clarity and completeness before submitting.
10. Mail the completed form and payment to the Division of Workers’ Compensation Record Search at the provided address.

Start your process today by completing the Missouri Authorization To Release Information (WC-126-AI) online.