I certify that the previous information in this form is true to the best of my knowledge and I authorize the release to my employer and workers’ compensation company all records relevant to my disability and my claim for disability or workers’ compensation benefits, including but not limited to medical diagnosis, prognosis, treatment, and periods of hospitalization. It is understood that the company will use the information to verify my disability and determine my eligibility of appropriate benefits. This authorization applies to physicians and other health care providers, hospitals, clinics, insurance companies, workers’ compensation carriers, and organizations administering benefit programs. This authorization will remain in effect throughout my claim for workers’ compensation benefits. I understand that I have the right to revoke this authorization in writing. A photocopy of this authorization will be as valid as the original.