I authorize FPO to conduct an impartial review into my complaint.
The FPO will collect my personal information directly from the WCB, AC and MPO pursuant to section 23.2(4) of the Workers’ Compensation Act.
I authorize the FPO to collect information, including personal information, about my claim verbally, electronically, in writing and/or in person for the purpose of providing fairness review services. The WCB, AC and MPO is authorized to disclose personal information to the FRB that is necessary for the purpose of providing fairness review services. This includes, but is not limited to, a copy of my claim file and copies of correspondence sent to me by the WCB, AC and MPO.
Expiry of Authorization
This authorization will expire when one of the following occurs:
Should you wish to revise or rescind this authorization, you are responsible for submitting a written notification to your fairness review officer. You may also submit the request in writing to the FPO at firstname.lastname@example.org.
Should you require further assistance from the FRB following the expiry of this authorization; you will be required to submit a new authorization form.
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