Accident Report (Employee)

Accident LocationVowels

Districtregion1_gr_branches

Supervisor NameSpike Lemmer

Date of Accident10/13/2021

Time of Accident10:30 AM

Employee NameApril Kremsreiter

Address1325 E Bellows ST
Apt C1
Mt pleasant, MI 48858
Map It

Phone(989) 294-3110

Date of Birth01/30/1979

Last 4 digits of your Social Security Number7437

Do you think you need to see a doctor today?Yes

Description of Accident

I was cleaning lockers and I went to go swipe up to clean and wipe them down and I got jammed on the inside of the locker thing to open it and it bit my wrist back now it's hard to bend it not very far and it sends shooting pains up the right side of my right wrist when I'm not even moving it. Now every time I move it and bend it it pops

What part of your body has been injured? Check all that apply
  • Right Wrist

AuthorizationThis electronic signature is authorization for any and all Health Care Providers, including but limited to Hospitals, Clinics, Physician Offices, Diagnostic Centers and Therapy Facilities.

I , the undersigned, hereby authorize the Custodian of Records of health care providers to which this authorization has been directed to release any and all information which may be requested regarding myself and to photocopy any records regarding me, including records which have been maintained regarding my past or present physical or mental condition and treatment rendered, including but limited to my consumption of alcohol or use of drugs including those protected under Title 242 of the Code of Federal Regulations, Part 2; Psychological or Psychiatric records, including communications made by me to a social workers, psychologist or psychiatrist; including behavioral or mental health services.

All records for any and all dates of evaluation, care or treatment to be disclosed.

Make disclosure to: York, Risk Services Group, Inc. PO Box 620 Howell, MI 48844‐0620

The purpose and need for disclosure is: At the request of the undersigned to process the above reference claim.

As a claimant, I may revoke this authorization by notifying the Custodian of Records of applicable health care provider in writing of my desire to revoke it. However, I understand that any action already taken in reliance on this authorization cannot be reversed, and my revocation will not affect those actions.

This authorization expires one year from the date of execution.

A PHOTOCOPY OR DIGITALLY SHARED COPY OF THIS DOCUMENT SHALL BE CONSIDERED VALID AS IF THE ORIGINAL WERE OFFERED.

Electronic SignatureApril Dawn Kremsreiter

Date10/13/2021

Accident LocationCedar view

Districtcedar_springs

Supervisor NameReba Hulliberger

Date of Accident10/11/2021

Time of Accident06:00 PM

Employee NameReba Hulliberger

Address11871 Newcosta ave
Sand lake, MIchigan 49343
Map It

Phone(616) 690-5493

Date of Birth01/10/1998

Last 4 digits of your Social Security Number1010

Do you think you need to see a doctor today?No

Description of Accident

I was vacuuming at view and I had to go lock a door and I was on the phone with Stacey and I slipped on my floor and about falled but nothing hurt until about hour or so after so I don't know if I moved just right vacuuming or when I about fell

What part of your body has been injured? Check all that apply
  • Upper Back
  • Middle Back
  • Lower Back

AuthorizationThis electronic signature is authorization for any and all Health Care Providers, including but limited to Hospitals, Clinics, Physician Offices, Diagnostic Centers and Therapy Facilities.

I , the undersigned, hereby authorize the Custodian of Records of health care providers to which this authorization has been directed to release any and all information which may be requested regarding myself and to photocopy any records regarding me, including records which have been maintained regarding my past or present physical or mental condition and treatment rendered, including but limited to my consumption of alcohol or use of drugs including those protected under Title 242 of the Code of Federal Regulations, Part 2; Psychological or Psychiatric records, including communications made by me to a social workers, psychologist or psychiatrist; including behavioral or mental health services.

All records for any and all dates of evaluation, care or treatment to be disclosed.

Make disclosure to: York, Risk Services Group, Inc. PO Box 620 Howell, MI 48844‐0620

The purpose and need for disclosure is: At the request of the undersigned to process the above reference claim.

As a claimant, I may revoke this authorization by notifying the Custodian of Records of applicable health care provider in writing of my desire to revoke it. However, I understand that any action already taken in reliance on this authorization cannot be reversed, and my revocation will not affect those actions.

This authorization expires one year from the date of execution.

A PHOTOCOPY OR DIGITALLY SHARED COPY OF THIS DOCUMENT SHALL BE CONSIDERED VALID AS IF THE ORIGINAL WERE OFFERED.

Electronic SignatureReba Hulliberger

Date10/11/2021

Accident LocationHartland, MI

Districtoffice

Supervisor NameJames Gee

Date of Accident10/11/2021

Time of Accident10:05 PM

Employee NameJames Gee

Address8571 e townline lake rd
Harrison, MI 48625
Map It

Phone(989) 621-9329

Date of Birth11/29/1976

Last 4 digits of your Social Security Number0313

Do you think you need to see a doctor today?No

Description of Accident

Car accident. Animal ran out in front of me. Swerved to miss, got caught in soft, wet, grassy shod of road. Hit electric pole

What part of your body has been injured? Check all that apply
  • Right Shoulder

AuthorizationThis electronic signature is authorization for any and all Health Care Providers, including but limited to Hospitals, Clinics, Physician Offices, Diagnostic Centers and Therapy Facilities.

I , the undersigned, hereby authorize the Custodian of Records of health care providers to which this authorization has been directed to release any and all information which may be requested regarding myself and to photocopy any records regarding me, including records which have been maintained regarding my past or present physical or mental condition and treatment rendered, including but limited to my consumption of alcohol or use of drugs including those protected under Title 242 of the Code of Federal Regulations, Part 2; Psychological or Psychiatric records, including communications made by me to a social workers, psychologist or psychiatrist; including behavioral or mental health services.

All records for any and all dates of evaluation, care or treatment to be disclosed.

Make disclosure to: York, Risk Services Group, Inc. PO Box 620 Howell, MI 48844‐0620

The purpose and need for disclosure is: At the request of the undersigned to process the above reference claim.

As a claimant, I may revoke this authorization by notifying the Custodian of Records of applicable health care provider in writing of my desire to revoke it. However, I understand that any action already taken in reliance on this authorization cannot be reversed, and my revocation will not affect those actions.

This authorization expires one year from the date of execution.

A PHOTOCOPY OR DIGITALLY SHARED COPY OF THIS DOCUMENT SHALL BE CONSIDERED VALID AS IF THE ORIGINAL WERE OFFERED.

Electronic SignatureJames gee

Date10/11/2021

Accident LocationGym

Districtcedar_springs

Supervisor NameReba Hulliberger

Date of Accident09/27/2021

Time of Accident07:10 AM

Employee NameSara Zandstra

Address16222 Ritchie
Sand Lake, Michigan 49343-9604
Map It

Phone(616) 690-5493

Date of Birth03/29/1994

Last 4 digits of your Social Security Number0478

Do you think you need to see a doctor today?Yes

Description of Accident

She was cleaning the stairs in the gym Bleachers . And she fell and Caught herself she took some ibuprofen and sat down for a few minutes and she went to walk into the gym to put bleachers away and she said there is A-sharp pain going up her leg

What part of your body has been injured? Check all that apply
  • Right Wrist
  • Right Ankle
  • Right Foot

AuthorizationThis electronic signature is authorization for any and all Health Care Providers, including but limited to Hospitals, Clinics, Physician Offices, Diagnostic Centers and Therapy Facilities.

I , the undersigned, hereby authorize the Custodian of Records of health care providers to which this authorization has been directed to release any and all information which may be requested regarding myself and to photocopy any records regarding me, including records which have been maintained regarding my past or present physical or mental condition and treatment rendered, including but limited to my consumption of alcohol or use of drugs including those protected under Title 242 of the Code of Federal Regulations, Part 2; Psychological or Psychiatric records, including communications made by me to a social workers, psychologist or psychiatrist; including behavioral or mental health services.

All records for any and all dates of evaluation, care or treatment to be disclosed.

Make disclosure to: York, Risk Services Group, Inc. PO Box 620 Howell, MI 48844‐0620

The purpose and need for disclosure is: At the request of the undersigned to process the above reference claim.

As a claimant, I may revoke this authorization by notifying the Custodian of Records of applicable health care provider in writing of my desire to revoke it. However, I understand that any action already taken in reliance on this authorization cannot be reversed, and my revocation will not affect those actions.

This authorization expires one year from the date of execution.

A PHOTOCOPY OR DIGITALLY SHARED COPY OF THIS DOCUMENT SHALL BE CONSIDERED VALID AS IF THE ORIGINAL WERE OFFERED.

Electronic SignatureReba Hulliberger

Date09/27/2021

Accident LocationGaylord High school

Districtgaylord

Supervisor NameJessica Perry

Date of Accident09/27/2021

Time of Accident01:30 AM

Employee NameJosef Elswick

Address17880 south straits highway
Vanderbilt, MIchigan 49795
Map It

Phone(734) 556-0075

Date of Birth03/28/2000

Last 4 digits of your Social Security Number1706

Do you think you need to see a doctor today?Not Sure

Description of Accident

Was pulling trash and thinks he slipped a disc and is in pain

What part of your body has been injured? Check all that apply
  • Upper Back

AuthorizationThis electronic signature is authorization for any and all Health Care Providers, including but limited to Hospitals, Clinics, Physician Offices, Diagnostic Centers and Therapy Facilities.

I , the undersigned, hereby authorize the Custodian of Records of health care providers to which this authorization has been directed to release any and all information which may be requested regarding myself and to photocopy any records regarding me, including records which have been maintained regarding my past or present physical or mental condition and treatment rendered, including but limited to my consumption of alcohol or use of drugs including those protected under Title 242 of the Code of Federal Regulations, Part 2; Psychological or Psychiatric records, including communications made by me to a social workers, psychologist or psychiatrist; including behavioral or mental health services.

All records for any and all dates of evaluation, care or treatment to be disclosed.

Make disclosure to: York, Risk Services Group, Inc. PO Box 620 Howell, MI 48844‐0620

The purpose and need for disclosure is: At the request of the undersigned to process the above reference claim.

As a claimant, I may revoke this authorization by notifying the Custodian of Records of applicable health care provider in writing of my desire to revoke it. However, I understand that any action already taken in reliance on this authorization cannot be reversed, and my revocation will not affect those actions.

This authorization expires one year from the date of execution.

A PHOTOCOPY OR DIGITALLY SHARED COPY OF THIS DOCUMENT SHALL BE CONSIDERED VALID AS IF THE ORIGINAL WERE OFFERED.

Electronic SignatureJosef Elswick

Date09/27/2021

Accident LocationLakeview middle school

Districtlakeview_bc

Supervisor NameShane Peterson

Date of Accident09/21/2021

Time of Accident01:25 PM

Employee NameSamantha Kilbourn

Address31 maple terrace
Battle creek, MIchigan 49917
Map It

Phone(269) 719-9396

Date of Birth07/26/1988

Last 4 digits of your Social Security Number3451

Do you think you need to see a doctor today?No

Description of Accident

I went to left a table and it felt like I pulled a muscle or Nerve. it started burning and I could barely move at 1st. It's in my lower back and butt area .

What part of your body has been injured? Check all that apply
  • Lower Back

AuthorizationThis electronic signature is authorization for any and all Health Care Providers, including but limited to Hospitals, Clinics, Physician Offices, Diagnostic Centers and Therapy Facilities.

I , the undersigned, hereby authorize the Custodian of Records of health care providers to which this authorization has been directed to release any and all information which may be requested regarding myself and to photocopy any records regarding me, including records which have been maintained regarding my past or present physical or mental condition and treatment rendered, including but limited to my consumption of alcohol or use of drugs including those protected under Title 242 of the Code of Federal Regulations, Part 2; Psychological or Psychiatric records, including communications made by me to a social workers, psychologist or psychiatrist; including behavioral or mental health services.

All records for any and all dates of evaluation, care or treatment to be disclosed.

Make disclosure to: York, Risk Services Group, Inc. PO Box 620 Howell, MI 48844‐0620

The purpose and need for disclosure is: At the request of the undersigned to process the above reference claim.

As a claimant, I may revoke this authorization by notifying the Custodian of Records of applicable health care provider in writing of my desire to revoke it. However, I understand that any action already taken in reliance on this authorization cannot be reversed, and my revocation will not affect those actions.

This authorization expires one year from the date of execution.

A PHOTOCOPY OR DIGITALLY SHARED COPY OF THIS DOCUMENT SHALL BE CONSIDERED VALID AS IF THE ORIGINAL WERE OFFERED.

Electronic SignatureSamantha kilbourn

Date09/21/2021

Accident Locationecc sparta

Districtoffice

Supervisor Namepenny hughes

Date of Accident09/20/2021

Time of Accident01:00 PM

Employee Namepenny hughes

Address629 graceland
grand rapids, MIchigan 49505
Map It

Phone(616) 272-1276

Date of Birth05/17/1961

Last 4 digits of your Social Security Number8978

Do you think you need to see a doctor today?No

Description of Accident

was stung taking the trash out.

What part of your body has been injured? Check all that apply
  • Right Wrist

AuthorizationThis electronic signature is authorization for any and all Health Care Providers, including but limited to Hospitals, Clinics, Physician Offices, Diagnostic Centers and Therapy Facilities.

I , the undersigned, hereby authorize the Custodian of Records of health care providers to which this authorization has been directed to release any and all information which may be requested regarding myself and to photocopy any records regarding me, including records which have been maintained regarding my past or present physical or mental condition and treatment rendered, including but limited to my consumption of alcohol or use of drugs including those protected under Title 242 of the Code of Federal Regulations, Part 2; Psychological or Psychiatric records, including communications made by me to a social workers, psychologist or psychiatrist; including behavioral or mental health services.

All records for any and all dates of evaluation, care or treatment to be disclosed.

Make disclosure to: York, Risk Services Group, Inc. PO Box 620 Howell, MI 48844‐0620

The purpose and need for disclosure is: At the request of the undersigned to process the above reference claim.

As a claimant, I may revoke this authorization by notifying the Custodian of Records of applicable health care provider in writing of my desire to revoke it. However, I understand that any action already taken in reliance on this authorization cannot be reversed, and my revocation will not affect those actions.

This authorization expires one year from the date of execution.

A PHOTOCOPY OR DIGITALLY SHARED COPY OF THIS DOCUMENT SHALL BE CONSIDERED VALID AS IF THE ORIGINAL WERE OFFERED.

Electronic Signaturepenny hughes

Date09/20/2021

Accident LocationLathers Elementary School

Districtgarden_city

Supervisor NameBeth M

Date of Accident09/16/2021

Time of Accident07:59 AM

Employee NameSamelle Legreair

Address10113 Elmira Street
Detroit, MIchigan 48204
Map It

Phone(313) 801-1904

Date of Birth11/18/1991

Last 4 digits of your Social Security Number2797

Do you think you need to see a doctor today?Yes

Description of Accident

Principal Wrote A Note Asking For Me To Move Tables Around In The Library To Make A Big Open Space For A Cpr Class They Are Having This Morning Upon Moving The Tables My Back Popped and I Felt Pain Shooting Down My Back…To The Point I Could Barely Walk Straight…I Notified My Supervisor Of The Incident I Also Notified Our HR Wellness & Safety Manager

What part of your body has been injured? Check all that apply
  • Right Leg
  • Lower Back

AuthorizationThis electronic signature is authorization for any and all Health Care Providers, including but limited to Hospitals, Clinics, Physician Offices, Diagnostic Centers and Therapy Facilities.

I , the undersigned, hereby authorize the Custodian of Records of health care providers to which this authorization has been directed to release any and all information which may be requested regarding myself and to photocopy any records regarding me, including records which have been maintained regarding my past or present physical or mental condition and treatment rendered, including but limited to my consumption of alcohol or use of drugs including those protected under Title 242 of the Code of Federal Regulations, Part 2; Psychological or Psychiatric records, including communications made by me to a social workers, psychologist or psychiatrist; including behavioral or mental health services.

All records for any and all dates of evaluation, care or treatment to be disclosed.

Make disclosure to: York, Risk Services Group, Inc. PO Box 620 Howell, MI 48844‐0620

The purpose and need for disclosure is: At the request of the undersigned to process the above reference claim.

As a claimant, I may revoke this authorization by notifying the Custodian of Records of applicable health care provider in writing of my desire to revoke it. However, I understand that any action already taken in reliance on this authorization cannot be reversed, and my revocation will not affect those actions.

This authorization expires one year from the date of execution.

A PHOTOCOPY OR DIGITALLY SHARED COPY OF THIS DOCUMENT SHALL BE CONSIDERED VALID AS IF THE ORIGINAL WERE OFFERED.

Electronic SignatureSamelle Legreair

Date09/16/2021

Accident LocationECC

Districtsparta

Supervisor NameJodi Hawley-Jack

Date of Accident09/07/2021

Time of Accident08:40 PM

Employee NameMichael Fox

Address1770 Daisy Lane
Kent City, MIchigan 49330
Map It

Phone(616) 319-9092

Date of Birth02/10/1960

Last 4 digits of your Social Security Number3661

Do you think you need to see a doctor today?Not Sure

Description of Accident

Employee said he was walking down hall lights did not come on and slipped in a puddle of water in the hall. Said he fell hurt his ankle and leg.

What part of your body has been injured? Check all that apply
  • Right Leg
  • Right Ankle
  • Right Foot

AuthorizationThis electronic signature is authorization for any and all Health Care Providers, including but limited to Hospitals, Clinics, Physician Offices, Diagnostic Centers and Therapy Facilities.

I , the undersigned, hereby authorize the Custodian of Records of health care providers to which this authorization has been directed to release any and all information which may be requested regarding myself and to photocopy any records regarding me, including records which have been maintained regarding my past or present physical or mental condition and treatment rendered, including but limited to my consumption of alcohol or use of drugs including those protected under Title 242 of the Code of Federal Regulations, Part 2; Psychological or Psychiatric records, including communications made by me to a social workers, psychologist or psychiatrist; including behavioral or mental health services.

All records for any and all dates of evaluation, care or treatment to be disclosed.

Make disclosure to: York, Risk Services Group, Inc. PO Box 620 Howell, MI 48844‐0620

The purpose and need for disclosure is: At the request of the undersigned to process the above reference claim.

As a claimant, I may revoke this authorization by notifying the Custodian of Records of applicable health care provider in writing of my desire to revoke it. However, I understand that any action already taken in reliance on this authorization cannot be reversed, and my revocation will not affect those actions.

This authorization expires one year from the date of execution.

A PHOTOCOPY OR DIGITALLY SHARED COPY OF THIS DOCUMENT SHALL BE CONSIDERED VALID AS IF THE ORIGINAL WERE OFFERED.

Electronic SignatureMichael Fox / Jodi Hawley-Jack

Date09/08/2021

Accident LocationFarmington East Middle School

Districtfarmington

Supervisor NameNick Langendorfer

Date of Accident08/31/2021

Time of Accident09:00 AM

Employee NameShawn Proffit

Address56445 Scotland Blvd
Shelby Twp, MIchigan 48316
Map It

Phone(248) 533-6238

Date of Birth06/29/1970

Last 4 digits of your Social Security Number7023

Do you think you need to see a doctor today?Not Sure

Description of Accident

I was asked by Principal Sanders to throw away some shelves that the movers didn't throw away. They were to big to toss in the sliding door so I lifted them over my head to get into the dumpster

What part of your body has been injured? Check all that apply
  • Lower Back

AuthorizationThis electronic signature is authorization for any and all Health Care Providers, including but limited to Hospitals, Clinics, Physician Offices, Diagnostic Centers and Therapy Facilities.

I , the undersigned, hereby authorize the Custodian of Records of health care providers to which this authorization has been directed to release any and all information which may be requested regarding myself and to photocopy any records regarding me, including records which have been maintained regarding my past or present physical or mental condition and treatment rendered, including but limited to my consumption of alcohol or use of drugs including those protected under Title 242 of the Code of Federal Regulations, Part 2; Psychological or Psychiatric records, including communications made by me to a social workers, psychologist or psychiatrist; including behavioral or mental health services.

All records for any and all dates of evaluation, care or treatment to be disclosed.

Make disclosure to: York, Risk Services Group, Inc. PO Box 620 Howell, MI 48844‐0620

The purpose and need for disclosure is: At the request of the undersigned to process the above reference claim.

As a claimant, I may revoke this authorization by notifying the Custodian of Records of applicable health care provider in writing of my desire to revoke it. However, I understand that any action already taken in reliance on this authorization cannot be reversed, and my revocation will not affect those actions.

This authorization expires one year from the date of execution.

A PHOTOCOPY OR DIGITALLY SHARED COPY OF THIS DOCUMENT SHALL BE CONSIDERED VALID AS IF THE ORIGINAL WERE OFFERED.

Electronic SignatureShawn Proffit

Date08/31/2021

Accident LocationLakeview Highschool Battle Creek MI

Districtlakeview_bc

Supervisor NameRichard N/A

Date of Accident08/23/2021

Time of Accident04:00 PM

Employee NameJaiden Reed

Address447 N 23rd St.
Springfield, MIchigan 49037
Map It

Phone(269) 569-2548

Date of Birth06/27/1998

Last 4 digits of your Social Security Number1855

Do you think you need to see a doctor today?Yes

Description of Accident

I was asked by athletic staff to move all the entry rugs on the first floor and basement between the gym and pool. I was Lifting 40-50 pound rugs and pulled a muscle in my right shoulder and right side of neck.

What part of your body has been injured? Check all that apply
  • Upper Back
  • Right Shoulder

AuthorizationThis electronic signature is authorization for any and all Health Care Providers, including but limited to Hospitals, Clinics, Physician Offices, Diagnostic Centers and Therapy Facilities.

I , the undersigned, hereby authorize the Custodian of Records of health care providers to which this authorization has been directed to release any and all information which may be requested regarding myself and to photocopy any records regarding me, including records which have been maintained regarding my past or present physical or mental condition and treatment rendered, including but limited to my consumption of alcohol or use of drugs including those protected under Title 242 of the Code of Federal Regulations, Part 2; Psychological or Psychiatric records, including communications made by me to a social workers, psychologist or psychiatrist; including behavioral or mental health services.

All records for any and all dates of evaluation, care or treatment to be disclosed.

Make disclosure to: York, Risk Services Group, Inc. PO Box 620 Howell, MI 48844‐0620

The purpose and need for disclosure is: At the request of the undersigned to process the above reference claim.

As a claimant, I may revoke this authorization by notifying the Custodian of Records of applicable health care provider in writing of my desire to revoke it. However, I understand that any action already taken in reliance on this authorization cannot be reversed, and my revocation will not affect those actions.

This authorization expires one year from the date of execution.

A PHOTOCOPY OR DIGITALLY SHARED COPY OF THIS DOCUMENT SHALL BE CONSIDERED VALID AS IF THE ORIGINAL WERE OFFERED.

Electronic SignatureJaiden reed

Date08/26/2021

Accident LocationCedar springs middle school

Districtoffice

Supervisor NameNicholas Langendorfer

Date of Accident08/20/2021

Time of Accident01:40 PM

Employee NameStacey Drayer

Address3656 mapledge
Cedar springs, MI 49319
Map It

Phone(616) 293-5468

Date of Birth11/17/1970

Last 4 digits of your Social Security Number1295

Do you think you need to see a doctor today?Not Sure

Description of Accident

Taking trash out feeling sharp pain in lower back.

As time goes on I have pain in right hip and leg.

Going home to take motrin and ice

What part of your body has been injured? Check all that apply
  • Right Leg
  • Lower Back

AuthorizationThis electronic signature is authorization for any and all Health Care Providers, including but limited to Hospitals, Clinics, Physician Offices, Diagnostic Centers and Therapy Facilities.

I , the undersigned, hereby authorize the Custodian of Records of health care providers to which this authorization has been directed to release any and all information which may be requested regarding myself and to photocopy any records regarding me, including records which have been maintained regarding my past or present physical or mental condition and treatment rendered, including but limited to my consumption of alcohol or use of drugs including those protected under Title 242 of the Code of Federal Regulations, Part 2; Psychological or Psychiatric records, including communications made by me to a social workers, psychologist or psychiatrist; including behavioral or mental health services.

All records for any and all dates of evaluation, care or treatment to be disclosed.

Make disclosure to: York, Risk Services Group, Inc. PO Box 620 Howell, MI 48844‐0620

The purpose and need for disclosure is: At the request of the undersigned to process the above reference claim.

As a claimant, I may revoke this authorization by notifying the Custodian of Records of applicable health care provider in writing of my desire to revoke it. However, I understand that any action already taken in reliance on this authorization cannot be reversed, and my revocation will not affect those actions.

This authorization expires one year from the date of execution.

A PHOTOCOPY OR DIGITALLY SHARED COPY OF THIS DOCUMENT SHALL BE CONSIDERED VALID AS IF THE ORIGINAL WERE OFFERED.

Electronic SignatureStacey Drayer

Date08/20/2021

Accident LocationIonia high school

Districtionia

Supervisor Nametracy wireman

Date of Accident08/18/2021

Time of Accident08:00 PM

Employee NameCynthia Lake

Address5218 Harwood Rd
Ionia, MI 48846
Map It

Phone(616) 755-1474

Date of Birth03/23/2021

Last 4 digits of your Social Security Number2120

Do you think you need to see a doctor today?Yes

Description of Accident

moving a locker and stepped wrong

What part of your body has been injured? Check all that apply
  • Right Knee

AuthorizationThis electronic signature is authorization for any and all Health Care Providers, including but limited to Hospitals, Clinics, Physician Offices, Diagnostic Centers and Therapy Facilities.

I , the undersigned, hereby authorize the Custodian of Records of health care providers to which this authorization has been directed to release any and all information which may be requested regarding myself and to photocopy any records regarding me, including records which have been maintained regarding my past or present physical or mental condition and treatment rendered, including but limited to my consumption of alcohol or use of drugs including those protected under Title 242 of the Code of Federal Regulations, Part 2; Psychological or Psychiatric records, including communications made by me to a social workers, psychologist or psychiatrist; including behavioral or mental health services.

All records for any and all dates of evaluation, care or treatment to be disclosed.

Make disclosure to: York, Risk Services Group, Inc. PO Box 620 Howell, MI 48844‐0620

The purpose and need for disclosure is: At the request of the undersigned to process the above reference claim.

As a claimant, I may revoke this authorization by notifying the Custodian of Records of applicable health care provider in writing of my desire to revoke it. However, I understand that any action already taken in reliance on this authorization cannot be reversed, and my revocation will not affect those actions.

This authorization expires one year from the date of execution.

A PHOTOCOPY OR DIGITALLY SHARED COPY OF THIS DOCUMENT SHALL BE CONSIDERED VALID AS IF THE ORIGINAL WERE OFFERED.

Electronic SignatureCynthia Mae Lake

Date08/08/2021

Accident LocationRidgview

Districtsparta

Supervisor NameJodi Hawley Jack

Date of Accident08/17/2021

Time of Accident02:00 PM

Employee NameRobert Wylie

Address162 oak st
Rockford, MIchigan 49341
Map It

Phone(616) 481-2816

Date of Birth04/04/1955

Last 4 digits of your Social Security Number4685

Do you think you need to see a doctor today?No

Description of Accident

Moving a table table tipped and Bob tipped with it

What part of your body has been injured? Check all that apply
  • Right Wrist
  • Left Knee
  • Right Knee
  • Left Wrist

AuthorizationThis electronic signature is authorization for any and all Health Care Providers, including but limited to Hospitals, Clinics, Physician Offices, Diagnostic Centers and Therapy Facilities.

I , the undersigned, hereby authorize the Custodian of Records of health care providers to which this authorization has been directed to release any and all information which may be requested regarding myself and to photocopy any records regarding me, including records which have been maintained regarding my past or present physical or mental condition and treatment rendered, including but limited to my consumption of alcohol or use of drugs including those protected under Title 242 of the Code of Federal Regulations, Part 2; Psychological or Psychiatric records, including communications made by me to a social workers, psychologist or psychiatrist; including behavioral or mental health services.

All records for any and all dates of evaluation, care or treatment to be disclosed.

Make disclosure to: York, Risk Services Group, Inc. PO Box 620 Howell, MI 48844‐0620

The purpose and need for disclosure is: At the request of the undersigned to process the above reference claim.

As a claimant, I may revoke this authorization by notifying the Custodian of Records of applicable health care provider in writing of my desire to revoke it. However, I understand that any action already taken in reliance on this authorization cannot be reversed, and my revocation will not affect those actions.

This authorization expires one year from the date of execution.

A PHOTOCOPY OR DIGITALLY SHARED COPY OF THIS DOCUMENT SHALL BE CONSIDERED VALID AS IF THE ORIGINAL WERE OFFERED.

Electronic SignatureRobert Wylie

Date08/17/2021

Accident Location8 mile& Wyoming East bound Detroit

Districtpontiac

Supervisor NameMike Vandenberg

Date of Accident08/16/2021

Time of Accident08:30 AM

Employee NameJoseph Jones

Address37595 Scotsdale Cir
Apt 204
Westland, MIchigan 48185
Map It

Phone(205) 249-7277

Date of Birth03/09/1974

Last 4 digits of your Social Security Number3460

Do you think you need to see a doctor today?No

Description of Accident

I was sitting at the intersection in the far left lane, with a car in front of me. The light was out, so it was being treated like a full stop intersection.
I was hit from behind by a lady in a pick up truck. i called the police, and she apologized and we all traded information. I drove my truck home, but i realized the lights are out in the back, and its leaking some fluid. I called my insurance company, and ill have it towed to be repaired. I feel ok, just tired.

AuthorizationThis electronic signature is authorization for any and all Health Care Providers, including but limited to Hospitals, Clinics, Physician Offices, Diagnostic Centers and Therapy Facilities.

I , the undersigned, hereby authorize the Custodian of Records of health care providers to which this authorization has been directed to release any and all information which may be requested regarding myself and to photocopy any records regarding me, including records which have been maintained regarding my past or present physical or mental condition and treatment rendered, including but limited to my consumption of alcohol or use of drugs including those protected under Title 242 of the Code of Federal Regulations, Part 2; Psychological or Psychiatric records, including communications made by me to a social workers, psychologist or psychiatrist; including behavioral or mental health services.

All records for any and all dates of evaluation, care or treatment to be disclosed.

Make disclosure to: York, Risk Services Group, Inc. PO Box 620 Howell, MI 48844‐0620

The purpose and need for disclosure is: At the request of the undersigned to process the above reference claim.

As a claimant, I may revoke this authorization by notifying the Custodian of Records of applicable health care provider in writing of my desire to revoke it. However, I understand that any action already taken in reliance on this authorization cannot be reversed, and my revocation will not affect those actions.

This authorization expires one year from the date of execution.

A PHOTOCOPY OR DIGITALLY SHARED COPY OF THIS DOCUMENT SHALL BE CONSIDERED VALID AS IF THE ORIGINAL WERE OFFERED.

Electronic SignatureJoseph Jones

Date08/16/2021

Accident LocationBirmingham Covington Elementary School

Supervisor NameAlicia Nelson

Date of Accident08/07/2021

Time of Accident10:00 AM

Employee NameChelsie Sambrone

Address8124 Honeytree BLVD
Canton, MIchigan 48187
Map It

Phone(248) 326-4412

Date of Birth04/02/1993

Last 4 digits of your Social Security Number8858

Do you think you need to see a doctor today?No

Description of Accident

I was putting assurance on the floor and ended up slipping and falling. Fell on my bottom and legs.

What part of your body has been injured? Check all that apply
  • Right Leg

AuthorizationThis electronic signature is authorization for any and all Health Care Providers, including but limited to Hospitals, Clinics, Physician Offices, Diagnostic Centers and Therapy Facilities.

I , the undersigned, hereby authorize the Custodian of Records of health care providers to which this authorization has been directed to release any and all information which may be requested regarding myself and to photocopy any records regarding me, including records which have been maintained regarding my past or present physical or mental condition and treatment rendered, including but limited to my consumption of alcohol or use of drugs including those protected under Title 242 of the Code of Federal Regulations, Part 2; Psychological or Psychiatric records, including communications made by me to a social workers, psychologist or psychiatrist; including behavioral or mental health services.

All records for any and all dates of evaluation, care or treatment to be disclosed.

Make disclosure to: York, Risk Services Group, Inc. PO Box 620 Howell, MI 48844‐0620

The purpose and need for disclosure is: At the request of the undersigned to process the above reference claim.

As a claimant, I may revoke this authorization by notifying the Custodian of Records of applicable health care provider in writing of my desire to revoke it. However, I understand that any action already taken in reliance on this authorization cannot be reversed, and my revocation will not affect those actions.

This authorization expires one year from the date of execution.

A PHOTOCOPY OR DIGITALLY SHARED COPY OF THIS DOCUMENT SHALL BE CONSIDERED VALID AS IF THE ORIGINAL WERE OFFERED.

Electronic SignatureChelsie Sambrone

Date08/07/2021

Accident LocationTri county

Districtoffice

Supervisor NameAyla Noah

Date of Accident07/30/2021

Time of Accident11:00 AM

Employee Nameaustin Toner

Address18990 w Kimball rd
Pierson, MIchigan 49339
Map It

Phone(616) 262-2759

Date of Birth06/28/1991

Last 4 digits of your Social Security Number5558

Do you think you need to see a doctor today?Yes

Description of Accident

Was weed walking when got stung by several bees. Went to garage to report it and got dizzy and blacked out.

What part of your body has been injured? Check all that apply
  • Head
  • Right Leg
  • Left Leg

AuthorizationThis electronic signature is authorization for any and all Health Care Providers, including but limited to Hospitals, Clinics, Physician Offices, Diagnostic Centers and Therapy Facilities.

I , the undersigned, hereby authorize the Custodian of Records of health care providers to which this authorization has been directed to release any and all information which may be requested regarding myself and to photocopy any records regarding me, including records which have been maintained regarding my past or present physical or mental condition and treatment rendered, including but limited to my consumption of alcohol or use of drugs including those protected under Title 242 of the Code of Federal Regulations, Part 2; Psychological or Psychiatric records, including communications made by me to a social workers, psychologist or psychiatrist; including behavioral or mental health services.

All records for any and all dates of evaluation, care or treatment to be disclosed.

Make disclosure to: York, Risk Services Group, Inc. PO Box 620 Howell, MI 48844‐0620

The purpose and need for disclosure is: At the request of the undersigned to process the above reference claim.

As a claimant, I may revoke this authorization by notifying the Custodian of Records of applicable health care provider in writing of my desire to revoke it. However, I understand that any action already taken in reliance on this authorization cannot be reversed, and my revocation will not affect those actions.

This authorization expires one year from the date of execution.

A PHOTOCOPY OR DIGITALLY SHARED COPY OF THIS DOCUMENT SHALL BE CONSIDERED VALID AS IF THE ORIGINAL WERE OFFERED.

Electronic SignatureAustin Toner

Date07/30/2021

Accident LocationEmmerson Elementary

Districtionia

Supervisor NameTracy Wireman

Date of Accident07/30/2021

Time of Accident01:20 PM

Employee NameGloria Slater

Address1248 W MAIN ST
IONIA, MI 48846-1921
Map It

Phone(616) 842-8269

Date of Birth11/12/1961

Last 4 digits of your Social Security Number8789

Do you think you need to see a doctor today?No

Description of Accident

Open pump sprayer prior to letting pressure out, sprayed in eye, right side.
Used eye wash station.

What part of your body has been injured? Check all that apply
  • Right Eye

AuthorizationThis electronic signature is authorization for any and all Health Care Providers, including but limited to Hospitals, Clinics, Physician Offices, Diagnostic Centers and Therapy Facilities.

I , the undersigned, hereby authorize the Custodian of Records of health care providers to which this authorization has been directed to release any and all information which may be requested regarding myself and to photocopy any records regarding me, including records which have been maintained regarding my past or present physical or mental condition and treatment rendered, including but limited to my consumption of alcohol or use of drugs including those protected under Title 242 of the Code of Federal Regulations, Part 2; Psychological or Psychiatric records, including communications made by me to a social workers, psychologist or psychiatrist; including behavioral or mental health services.

All records for any and all dates of evaluation, care or treatment to be disclosed.

Make disclosure to: York, Risk Services Group, Inc. PO Box 620 Howell, MI 48844‐0620

The purpose and need for disclosure is: At the request of the undersigned to process the above reference claim.

As a claimant, I may revoke this authorization by notifying the Custodian of Records of applicable health care provider in writing of my desire to revoke it. However, I understand that any action already taken in reliance on this authorization cannot be reversed, and my revocation will not affect those actions.

This authorization expires one year from the date of execution.

A PHOTOCOPY OR DIGITALLY SHARED COPY OF THIS DOCUMENT SHALL BE CONSIDERED VALID AS IF THE ORIGINAL WERE OFFERED.

Electronic SignatureGloria Slater

Date07/30/2021

Accident LocationBirmingham District Bingham Elementaryin the hallway.

Districtoffice

Supervisor NameAlicia Nelson

Date of Accident07/29/2021

Time of Accident11:44 AM

Employee NameLaMonte ONeal

Address19400 Lasher RD
Detroit, MIchigan 48219
Map It

Phone(313) 656-8532

Date of Birth04/08/1981

Last 4 digits of your Social Security NumberI don't know

Do you think you need to see a doctor today?Not Sure

Description of Accident

I was moving desk and the desk pinched my ring finger on left hand. And now I see a blood clot.

What part of your body has been injured? Check all that apply
  • Left Hand

AuthorizationThis electronic signature is authorization for any and all Health Care Providers, including but limited to Hospitals, Clinics, Physician Offices, Diagnostic Centers and Therapy Facilities.

I , the undersigned, hereby authorize the Custodian of Records of health care providers to which this authorization has been directed to release any and all information which may be requested regarding myself and to photocopy any records regarding me, including records which have been maintained regarding my past or present physical or mental condition and treatment rendered, including but limited to my consumption of alcohol or use of drugs including those protected under Title 242 of the Code of Federal Regulations, Part 2; Psychological or Psychiatric records, including communications made by me to a social workers, psychologist or psychiatrist; including behavioral or mental health services.

All records for any and all dates of evaluation, care or treatment to be disclosed.

Make disclosure to: York, Risk Services Group, Inc. PO Box 620 Howell, MI 48844‐0620

The purpose and need for disclosure is: At the request of the undersigned to process the above reference claim.

As a claimant, I may revoke this authorization by notifying the Custodian of Records of applicable health care provider in writing of my desire to revoke it. However, I understand that any action already taken in reliance on this authorization cannot be reversed, and my revocation will not affect those actions.

This authorization expires one year from the date of execution.

A PHOTOCOPY OR DIGITALLY SHARED COPY OF THIS DOCUMENT SHALL BE CONSIDERED VALID AS IF THE ORIGINAL WERE OFFERED.

Electronic SignatureLaMonte Oneal

Date07/29/2021

Accident LocationKeefe

Districtoffice

Supervisor NamePenny Hughes

Date of Accident07/29/2021

Time of Accident12:30 PM

Employee NamePenny Hughes

Address629 Graceland
Grand rapids, Michigan 49329
Map It

Phone(616) 272-1276

Date of Birth05/17/1961

Last 4 digits of your Social Security Number8978

Do you think you need to see a doctor today?Not Sure

Description of Accident

Was bring trash to the dumpster and twisted her ankle. Boots were worn.

What part of your body has been injured? Check all that apply
  • Right Ankle

AuthorizationThis electronic signature is authorization for any and all Health Care Providers, including but limited to Hospitals, Clinics, Physician Offices, Diagnostic Centers and Therapy Facilities.

I , the undersigned, hereby authorize the Custodian of Records of health care providers to which this authorization has been directed to release any and all information which may be requested regarding myself and to photocopy any records regarding me, including records which have been maintained regarding my past or present physical or mental condition and treatment rendered, including but limited to my consumption of alcohol or use of drugs including those protected under Title 242 of the Code of Federal Regulations, Part 2; Psychological or Psychiatric records, including communications made by me to a social workers, psychologist or psychiatrist; including behavioral or mental health services.

All records for any and all dates of evaluation, care or treatment to be disclosed.

Make disclosure to: York, Risk Services Group, Inc. PO Box 620 Howell, MI 48844‐0620

The purpose and need for disclosure is: At the request of the undersigned to process the above reference claim.

As a claimant, I may revoke this authorization by notifying the Custodian of Records of applicable health care provider in writing of my desire to revoke it. However, I understand that any action already taken in reliance on this authorization cannot be reversed, and my revocation will not affect those actions.

This authorization expires one year from the date of execution.

A PHOTOCOPY OR DIGITALLY SHARED COPY OF THIS DOCUMENT SHALL BE CONSIDERED VALID AS IF THE ORIGINAL WERE OFFERED.

Electronic SignaturePenny hughes

Date07/29/2021

Accident LocationBelding

Districtbelding

Supervisor NameCraig Bannister

Date of Accident07/27/2021

Time of Accident11:30 AM

Employee NameKatryna Scheid

Address2291 n.hawley hwy
Belding,, MIchigan 48809
Map It

Phone(616) 755-5723

Date of Birth02/05/2000

Last 4 digits of your Social Security Number368-25-6639

Do you think you need to see a doctor today?Yes

Description of Accident

Pulling weeds and one went into the right eye

What part of your body has been injured? Check all that apply
  • Right Eye

AuthorizationThis electronic signature is authorization for any and all Health Care Providers, including but limited to Hospitals, Clinics, Physician Offices, Diagnostic Centers and Therapy Facilities.

I , the undersigned, hereby authorize the Custodian of Records of health care providers to which this authorization has been directed to release any and all information which may be requested regarding myself and to photocopy any records regarding me, including records which have been maintained regarding my past or present physical or mental condition and treatment rendered, including but limited to my consumption of alcohol or use of drugs including those protected under Title 242 of the Code of Federal Regulations, Part 2; Psychological or Psychiatric records, including communications made by me to a social workers, psychologist or psychiatrist; including behavioral or mental health services.

All records for any and all dates of evaluation, care or treatment to be disclosed.

Make disclosure to: York, Risk Services Group, Inc. PO Box 620 Howell, MI 48844‐0620

The purpose and need for disclosure is: At the request of the undersigned to process the above reference claim.

As a claimant, I may revoke this authorization by notifying the Custodian of Records of applicable health care provider in writing of my desire to revoke it. However, I understand that any action already taken in reliance on this authorization cannot be reversed, and my revocation will not affect those actions.

This authorization expires one year from the date of execution.

A PHOTOCOPY OR DIGITALLY SHARED COPY OF THIS DOCUMENT SHALL BE CONSIDERED VALID AS IF THE ORIGINAL WERE OFFERED.

Electronic SignatureKatryna scheid

Date07/28/2021

Accident LocationEdgerton

Districtoffice

Supervisor NameLillith Alberts

Date of Accident07/21/2021

Time of Accident09:00 AM

Employee NameRaquel Miller

Address2059 sunshine Dr apt b
Truant, MIchigan 49347
Map It

Phone(616) 344-8375

Date of Birth09/30/1970

Last 4 digits of your Social Security Number3664

Do you think you need to see a doctor today?No

Description of Accident

Was using a chair as step stool and fell of of it .

What part of your body has been injured? Check all that apply
  • Right Shoulder

AuthorizationThis electronic signature is authorization for any and all Health Care Providers, including but limited to Hospitals, Clinics, Physician Offices, Diagnostic Centers and Therapy Facilities.

I , the undersigned, hereby authorize the Custodian of Records of health care providers to which this authorization has been directed to release any and all information which may be requested regarding myself and to photocopy any records regarding me, including records which have been maintained regarding my past or present physical or mental condition and treatment rendered, including but limited to my consumption of alcohol or use of drugs including those protected under Title 242 of the Code of Federal Regulations, Part 2; Psychological or Psychiatric records, including communications made by me to a social workers, psychologist or psychiatrist; including behavioral or mental health services.

All records for any and all dates of evaluation, care or treatment to be disclosed.

Make disclosure to: York, Risk Services Group, Inc. PO Box 620 Howell, MI 48844‐0620

The purpose and need for disclosure is: At the request of the undersigned to process the above reference claim.

As a claimant, I may revoke this authorization by notifying the Custodian of Records of applicable health care provider in writing of my desire to revoke it. However, I understand that any action already taken in reliance on this authorization cannot be reversed, and my revocation will not affect those actions.

This authorization expires one year from the date of execution.

A PHOTOCOPY OR DIGITALLY SHARED COPY OF THIS DOCUMENT SHALL BE CONSIDERED VALID AS IF THE ORIGINAL WERE OFFERED.

Electronic SignatureRaquel Miller

Date07/21/2021

Accident LocationCedar Springs High School

Districtcedar_springs

Supervisor NameKeenan Keenan

Date of Accident07/21/2021

Time of Accident01:45 PM

Employee NameCheryl Ploughman

Address4700
N Nevins Rd
Stanton, MIchigan 48888
Map It

Phone(616) 375-8721

Date of Birth05/30/1972

Last 4 digits of your Social Security Number9253

Do you think you need to see a doctor today?No

Description of Accident

Was operating the lo-speed while stripping. I slipped on the stripping chemical and landed on my right elbow, hard, and both knees.

Below list does not give the option of right elbow/forearm

What part of your body has been injured? Check all that apply
  • Left Knee
  • Right Knee

AuthorizationThis electronic signature is authorization for any and all Health Care Providers, including but limited to Hospitals, Clinics, Physician Offices, Diagnostic Centers and Therapy Facilities.

I , the undersigned, hereby authorize the Custodian of Records of health care providers to which this authorization has been directed to release any and all information which may be requested regarding myself and to photocopy any records regarding me, including records which have been maintained regarding my past or present physical or mental condition and treatment rendered, including but limited to my consumption of alcohol or use of drugs including those protected under Title 242 of the Code of Federal Regulations, Part 2; Psychological or Psychiatric records, including communications made by me to a social workers, psychologist or psychiatrist; including behavioral or mental health services.

All records for any and all dates of evaluation, care or treatment to be disclosed.

Make disclosure to: York, Risk Services Group, Inc. PO Box 620 Howell, MI 48844‐0620

The purpose and need for disclosure is: At the request of the undersigned to process the above reference claim.

As a claimant, I may revoke this authorization by notifying the Custodian of Records of applicable health care provider in writing of my desire to revoke it. However, I understand that any action already taken in reliance on this authorization cannot be reversed, and my revocation will not affect those actions.

This authorization expires one year from the date of execution.

A PHOTOCOPY OR DIGITALLY SHARED COPY OF THIS DOCUMENT SHALL BE CONSIDERED VALID AS IF THE ORIGINAL WERE OFFERED.

Electronic SignatureCheryl Ploughman

Date07/21/2021

Accident LocationWayland High School cats den

Districtwayland

Supervisor NameAshley Stearns-McDaniel

Date of Accident07/21/2021

Time of Accident12:30 PM

Employee NameAshley Stearns-McDaniel

Address217 west Morrell streef
Otsego, MIchigan 49078
Map It

Phone(269) 251-7620

Date of Birth11/18/1986

Last 4 digits of your Social Security Number1055

Do you think you need to see a doctor today?No

Description of Accident

Gregg and I and the team from Wayland District were moving heavy tables to set up for the supervisor retreat, and my right ring finger got smashed in between two tables.

What part of your body has been injured? Check all that apply
  • Right Wrist

AuthorizationThis electronic signature is authorization for any and all Health Care Providers, including but limited to Hospitals, Clinics, Physician Offices, Diagnostic Centers and Therapy Facilities.

I , the undersigned, hereby authorize the Custodian of Records of health care providers to which this authorization has been directed to release any and all information which may be requested regarding myself and to photocopy any records regarding me, including records which have been maintained regarding my past or present physical or mental condition and treatment rendered, including but limited to my consumption of alcohol or use of drugs including those protected under Title 242 of the Code of Federal Regulations, Part 2; Psychological or Psychiatric records, including communications made by me to a social workers, psychologist or psychiatrist; including behavioral or mental health services.

All records for any and all dates of evaluation, care or treatment to be disclosed.

Make disclosure to: York, Risk Services Group, Inc. PO Box 620 Howell, MI 48844‐0620

The purpose and need for disclosure is: At the request of the undersigned to process the above reference claim.

As a claimant, I may revoke this authorization by notifying the Custodian of Records of applicable health care provider in writing of my desire to revoke it. However, I understand that any action already taken in reliance on this authorization cannot be reversed, and my revocation will not affect those actions.

This authorization expires one year from the date of execution.

A PHOTOCOPY OR DIGITALLY SHARED COPY OF THIS DOCUMENT SHALL BE CONSIDERED VALID AS IF THE ORIGINAL WERE OFFERED.

Electronic SignatureAshley Stearns-McDaniel

Date07/21/2021

Accident LocationHartland HS

Districthartland

Supervisor NameDamia Cargill

Date of Accident07/14/2021

Time of Accident06:07 AM

Employee NameBarbara Griffith

Address12231 Center Rd
Fenton, MIchigan 48430
Map It

Phone(989) 254-0183

Date of Birth01/08/1959

Last 4 digits of your Social Security Number7023

Do you think you need to see a doctor today?Yes

Description of Accident

I went into Receiving Room to turn on the light and open the door. Someone put a rolled up entrance mat in front of the door and because it was so dark I tripped over the rug. Right hand went forward to break the fall and now my arm is severely hurting. Do not understand why anyone would put a rug in front of a door where there is constant foot traffic, close the door and turn off the light.

What part of your body has been injured? Check all that apply
  • Right Wrist
  • Right Shoulder

AuthorizationThis electronic signature is authorization for any and all Health Care Providers, including but limited to Hospitals, Clinics, Physician Offices, Diagnostic Centers and Therapy Facilities.

I , the undersigned, hereby authorize the Custodian of Records of health care providers to which this authorization has been directed to release any and all information which may be requested regarding myself and to photocopy any records regarding me, including records which have been maintained regarding my past or present physical or mental condition and treatment rendered, including but limited to my consumption of alcohol or use of drugs including those protected under Title 242 of the Code of Federal Regulations, Part 2; Psychological or Psychiatric records, including communications made by me to a social workers, psychologist or psychiatrist; including behavioral or mental health services.

All records for any and all dates of evaluation, care or treatment to be disclosed.

Make disclosure to: York, Risk Services Group, Inc. PO Box 620 Howell, MI 48844‐0620

The purpose and need for disclosure is: At the request of the undersigned to process the above reference claim.

As a claimant, I may revoke this authorization by notifying the Custodian of Records of applicable health care provider in writing of my desire to revoke it. However, I understand that any action already taken in reliance on this authorization cannot be reversed, and my revocation will not affect those actions.

This authorization expires one year from the date of execution.

A PHOTOCOPY OR DIGITALLY SHARED COPY OF THIS DOCUMENT SHALL BE CONSIDERED VALID AS IF THE ORIGINAL WERE OFFERED.

Electronic SignatureBarbara Griffith

Date07/14/2021