The Advisor Office (AO) for Alberta Workers’ Compensation can provide advice about the WCB decision you are questioning, and your options for appealing. The AO can formally represent you at all levels of the WCB appeals process – WCB Customer Service, Dispute Resolution and Decision Review Body, and the Appeals Commission.

This form, when signed, allows the AO to gather information about your WCB claim(s) and represent you. Failure to complete all sections of this form may result in service delays.

A. Information About You

First Name

Middle Name

Last Name

Date of Birth

Phone

Email

Mailing Address

City

Province Alberta British Columbia Manitoba Newfoundland and Labrador New Brunswick Northwest Territories Nova Scotia Nunavut Ontario Prince Edward Island Quebec Saskatchewan Yukon

Postal Code

B. Scope of Representation

C. Details about Your Claim(s)

Claim Number 1

Date of WCB Decision Letter

What decision(s) do you want to review or appeal?

Claim Number 2

Date of WCB Decision Letter

What decision(s) do you want to review or appeal?

D. The Advisor Office as your Formal Representative

Formal Representative may access information about your claim(s) directly from WCB. Your Formal Representative has the authority to make representations on your behalf, can request a copy of your claim file, and receive a copy of correspondence sent to you. You can have only one Formal Representative.

E. Authorization to Collect Information from Workers’ Compensation Board

By signing, I authorize the AO to collect information, including personal information, about my claim(s) verbally, electronically, in writing, or in person from WCB for reviewing or appealing a WCB decision and providing advisory services. I authorize WCB to disclose personal information to the AO that is necessary for the purpose of providing appeals and advocacy services. This includes, but is not limited to, obtaining a copy of my claim file and copies of correspondence sent to me by WCB.

F. Authorization to Access and Share Medical Records

Medical records include personally identifiable information, diagnostic, treatment and care documentation. I authorize the AO to obtain, discuss, and share my medical records with my treating physician(s) or other medical provider(s) to seek clarification, or get an opinion on any medical matter related to my claim(s).

G. Term of Authorization

• This authorization will remain in effect for 3 years from the date signed below, unless you rescind it before. To change your authorization, you must notify the AO at advisoroffice@gov.ab.ca.
• Should you require further assistance on this matter or another matter following the expiry of this authorization, you must submit a new authorization form. We will contact you to update the authorization form about 3 months before it is set to expire.

H. Protection of Privacy

The AO collects and manages personal information under the authority of section 33(c) of the Freedom of Information and Protection of Privacy Act (Alberta). The AO will use your personal information for the purpose of reviewing claim(s) within Alberta’s workers’ compensation system. The information will also be used for providing appeals advisory services on your WCB claim(s).

Your personal information may also be used to contact you to complete a survey. The AO will not use or disclose your personal information 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 the AO toll-free at 1-866-427-0115, or advisoroffice@gov.ab.ca.

I. Service Commitment

I have read the AO Service Commitment and I acknowledge the terms set out in it.

J. Authorization

• I agree to the terms set out in this Service Request and Authorization;
• I have completed the Consent to Release Medical Information; and
• I want the AO to be my Formal Representative for the workers’ compensation matter(s).

Consent to Release Medical Information

This form authorizes the Advisor Office (AO) for Alberta Workers’ Compensation to contact your medical provider(s) to get medical record(s) related to your WCB claim(s). Medical records include personally identifiable information, diagnostic, treatment and care documentation.

First Name

Middle Name

Last Name

Date of Birth

A. Authorization

I, , authorize you to disclose my medical records to the AO, and understand why I have been asked to disclose these records. I understand the risks and benefits of consenting or refusing to consent. I understand I may revoke this consent in writing at any time.

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

B. Privacy Notice

The AO collects and manages personal information under the authority of section 33(c) of the Freedom of Information and Protection of Privacy Act (Alberta). The AO will use your personal information for the purpose of reviewing claim(s) within Alberta’s workers’ compensation system. The information will also be used for providing appeals and advisory services on your WCB claim(s).

Your personal information may also be used to contact you to complete a survey. The AO will not use or disclose your personal information 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 the AO toll-free at 1-866-427-0115, or advisoroffice@gov.ab.ca.

How did you learn about the Advisor Office?