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Worker’s authorisation

Brian Gerald Michael Foley Claim number: S17YT483910


Unit 6
16 Martin St
FORTITUDE VALLEY  QLD  4006

WorkCover Queensland requires your authorisation in order to manage your claim for compensation.

Release of information – your authorisation is required to obtain relevant medical and/or other
information from third parties.

➊ Authorisation

I Brian Gerald Michael Foley of Unit 6 16 Martin St FORTITUDE VALLEY QLD 4006, date of birth 11 October
1965, agree to advise WorkCover Queensland if my employment status changes during the currency of my
claim.

I authorise any doctor, health authority, allied health provider, rehabilitation provider, or other insurer to
disclose to WorkCover Queensland and its agents any information about my medical history relevant to this
claim for

on 14 February 2018.

I understand WorkCover Queensland may be required or authorised by law to release information or
documents to other parties.

Full Name

Claimant’s signature Date           /          /          

Online You can submit these documents via our website worksafe.qld.gov.au. Please click on the Online
services drop down, select “Send or request other information” and choose the “information on an existing claim”
option. Alternatively, you may utilise Worker Assist to upload this document. Please see our website for details.

By Fax Please fax this completed and signed Worker’s statement  to WorkCover Queensland on fax


1300 651 387. You do not need to send the original. Keep the original for your own records.

By post Please post this completed and signed form to GPO Box 2459, Brisbane Qld 4001.

The materials contained in this publication have been prepared by WorkCover Queensland for information purposes only and should not be considered
legal advice Information is current at time of publication. Page 1 of 1 IWAUTH01
ABN 40 577 162 756 S17YT483910