Alberta Fair Practices OfficeAlberta Fair Practices Office

Worker Appeal Authorization and Medical Release

Worker’s Authorization

Personal information you provide to the Alberta Fair Practices Office (FPO) is collected under the authority of section 33(c) of the Freedom of Information and Protection of Privacy Act (FOIP) and is managed in accordance with Part 2 of FOIP. The personal information you provide will be used by the FPO for the purpose of reviewing claims within the workers’ compensation system (Workers’ Compensation Board - Alberta (WCB), Appeals Commission for Alberta Workers’ Compensation (Appeals Commission), and the Medical Panels Office (MPO)), and to provide recommendations as a result of its review. The information will also be used for providing appeals and advisory services for your WCB claim.

Your personal information may also be used to contact you to complete a survey and will not be used or disclosed for any other purpose, without your written consent or unless required to do so by law. Should you have any questions pertaining to the collection of your personal information please contact Fair Practices office: Suite 1000, 10th Fl, 10123 – 99th St NW, Edmonton, AB T5J 3H1; info@fpo.alberta.ca or 1-866-427-0115.

Important Note: If any of the below information is not provided or is incomplete, it will cause a delay in proceeding with your file.

I authorize the FPO Worker Appeals Advisor Branch (WAAB) to represent me with respect to:

I authorize the FPO WAAB to collect information, including personal information, about my claim verbally, electronically, in writing and/or in person from the WCB for the purposes of reviewing and/or appealing a WCB decision and providing advocacy services. The WCB is authorized to disclose personal information to the FPO WAAB that is necessary for the purpose of providing appeals and advocacy services. This includes, but is not limited to, a copy of my claim file and copies of correspondence sent to me by the WCB.

I authorize the FPO WAAB to share and discuss my medical records with my treating physician(s) to seek clarification or get an opinion on any medical matter relating to my claim. If FPO WAAB requires medical information from my previous WCB claim files to determine past injuries and how they impact my current claim, I authorize FPO WAAB to obtain this information from the WCB.

This authorization will expire when one of the following occurs:

  • the appeal matter has been concluded
  • the services of the WAAB are no longer required; or
  • you rescind the authorization.

Should you wish to revise or rescind your authorization, you are responsible for submitting a written notification to the WAAB.

Should you require further assistance from the FPO WAAB following the expiry of this authorization, you will be required to submit a new authorization form.

Formal Representative may access information about your claim directly from the WCB. They have the authority to make representations on your behalf, can request a copy of your claim file and will receive a copy of correspondence sent to you.

An informal representative may assist you by providing and receiving information about your claim with WCB employees. They do not have the authority to make decisions on your behalf, cannot request a copy of your claim and will not receive a copy of correspondence sent to you. If you would like to appoint an informal representative, you must submit an Informal Representative Consent Form.

I authorize the FPO WAAB to act on my behalf for the purposes of assisting with my claim(s), which include reviewing and/orappealing a WCB decision. The FPO WAAB may make representations on my behalf and proceed with a documentary or inperson hearing in my absence if the FPO WAAB considers this action to be appropriate in the circumstances.

Consent to Release Medical Information

I, , authorize you to release copies of all information and medical reports, including psychological and psychiatric reports, and work history reports to the Alberta Fair Practices Office for the purpose of reviewing my workers’ compensation claim and/or pursuing any related appeal. I also authorize you to communicate with the Fair Practices Office if additional information or clarification is required.

Important Note: If any of the above information is not provided or is incomplete, it will cause a delay in proceeding with your file.

The Fair Practices Office may use and disclose the information as required or authorized by law and pursuant to the Freedom of Information and Protection of Privacy Act.

Form is not submitted

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FPO Authorization Terms

Workers Authorization

I authorize the FPO to collect information, including personal information, about my claim verbally, electronically, in writing and/or in person from the WCB for the purposes of reviewing and/or appealing a WCB decision and providing advocacy services. The WCB is authorized to disclose personal information to the FPO WAAB that is necessary for the purpose of providing appeals and advocacy services. This includes, but is not limited to, a copy of my claim file and copies of correspondence sent to me by the WCB.

Consent to Release Medical Information

I authorize FPO to obtain all information and medical reports, including psychological and psychiatric reports, and work history reports. The Fair Practices Office may use and disclose the information as required or authorized by law and pursuant to the Freedom of Information and Protection of Privacy Act.

Expiry of Authorization

The authorization will expire when one of the following occurs:

  • The appeal matter has been concluded
  • The services of the appeal advisor are no longer required: or
  • You rescind the authorization

Should you wish to revise or rescind the authorization, you are responsible for submitting a written notification to your appeal advisor. You may also submit the request in writing to the FPO at info@fpo.alberta.ca.

Should you require further assistance from the FPO following the expiry of this authorization; you will be required to submit a new authorization form.

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