Forms

Forms and authorizations

Most forms below open as a PDF. Where a form is fillable you can complete it on screen before printing; the rest need to be printed and completed by hand. All of them still require a wet or electronic signature and a date. A few items link out to the issuing agency, which is noted on each.

Order forms

Referral Order Form

Our order form, for when you would rather fax or email an order than use the online form. Covers workers’ compensation, civil and personal injury, Social Security, and other matters.

Fillable1 pageLopez & Associates

Open PDF Or order online →

Patient Directive for the Disclosure of Health, Employment, and Legal Records

Signed by the patient or their representative to direct a custodian to release records to Lopez & Associates. Cites California Civil Code § 56.11, 45 C.F.R. §§ 164.508 and 164.512, Welfare and Institutions Code § 5328, and 42 C.F.R. § 2.31.

Fillable2 pagesLopez & Associates

Open PDF

Federal agency authorizations

Use the agency’s own form when records are held by that agency. A general authorization is usually refused.

VA Form 10-5345 — Request for and Authorization to Release Health Information

For medical records held by the Department of Veterans Affairs. VA will not release records without this form completed accurately enough to locate them.

Fillable2 pagesU.S. Dept. of Veterans Affairs

Open PDF

DD Form 2870 — Authorization for Disclosure of Medical or Dental Information

For records held by a military treatment facility, dental treatment facility, or a Department of Defense health plan.

Fillable1 pageU.S. Dept. of Defense

Open PDF

Form SSA-3288 — Consent for Release of Information

Authorizes the Social Security Administration to release records about a person, a minor, or a legally incompetent adult. Proof of relationship is required if the signer is not the subject of the record.

Print and complete3 pagesSocial Security Administration

Open PDF

Form SSA-7050-F4 — Request for Social Security Earnings Information

For an earnings history: certified or non-certified detailed earnings, including periods of employment or self-employment and the names and addresses of employers. Not the form for free yearly totals.

Print and complete4 pagesSocial Security AdministrationFee applies

Open PDF

California state agencies

Form DE 5600 — Authorization for Release of Records

For records held by the California Employment Development Department. The form must be completed in full and mailed to the EDD address selected on it.

Fillable2 pagesCalifornia EDD

Open PDF

EAMS e-form filing

Registration documents for parties who file electronically with the Division of Workers’ Compensation. These are DWC’s documents, not ours, and DWC revises them — its e-form filers page is the source of record and also carries the training, the additional conditions and the filing guides that registration requires.

DWC eForm Filers — registration portal

The DWC page that governs the process: the agreement, the required training and quiz, the additional conditions, the e-form filing reference guide, and the EFORMS@dir.ca.gov address for submitting them. Start here.

External linkCalifornia DWC

Open DWC page

EAMS E-form Application and Agreement

The application and agreement a firm signs to become a registered EAMS e-form filer. Check it against DWC’s copy before signing — a superseded version can hold up a registration.

Print and completeCalifornia DWC

Open PDF DWC copy →

E-form Agreement Spreadsheet

The companion spreadsheet listing the filers to be registered under the agreement. Downloaded from DWC directly — spreadsheets are not served from this site.

SpreadsheetExternal linkCalifornia DWC

Get from DWC

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Federal and state agencies revise their forms periodically. If a custodian rejects one of these as outdated, tell us and we will replace it. Which authorization a matter requires is a question for your counsel — we can say what a custodian has asked for, not what your case needs.