How to Fill Out and Submit Form OC-110A: Scope, Delivery, and Record Use

Form OC-110A is the one-page authorization a New York workers’ compensation claimant signs to let the Workers’ Compensation Board release claim records to a specific person or organization. Fill in your name, case number or date of accident, and the recipient’s full name and mailing address; sign in ink; and mail the original to the Board’s Binghamton PO box. The Board does not accept this form by email, fax, or web upload.¹

When You Actually Need This Form

Workers’ compensation claim records are confidential under Workers’ Compensation Law Section 110-a. You only need OC-110A when you want to release your records to someone outside the group the statute already lets in. You and your attorney, your employer and its insurance carrier, Board staff, treating physicians, and certain government agencies and authorized researchers can access the file without your signature.² OC-110A exists for everyone else: a personal injury attorney handling a separate lawsuit, a new insurance company, a family member managing your affairs.

One request the form will not honor: a prospective employer. The top of OC-110A states in capital letters that you cannot authorize release of workers’ compensation information to prospective employers or for assessing your fitness for employment. If a hiring process asks you to sign one, the Board will not act on it.³

Filling Out the Form

Download the current PDF from wcb.ny.gov. A warning across the top reads: “PLEASE COMPLETE ALL ITEMS. AN INCOMPLETE FORM WILL DELAY THE PROCESSING OF YOUR REQUEST.”³

You will provide:

Your full legal name, as it appears on the claim.
Your Social Security or Tax Identification Number. This field is voluntary; leaving it blank will not get the form denied, but including it helps the Board match the authorization to the right file.³
The case number and/or date of accident, with the box checked for the type of case (workers’ compensation, discrimination, paid family leave, or disability benefits). For multiple files, list the additional case numbers or accident dates in the space provided.
The recipient’s full legal name and complete mailing address. A vague recipient means no delivery.
Your signature and the date. Sign in ink, blue if possible. The form states “ink only.”

What the form does not ask for: your home address, your phone number, or a notary stamp. OC-110A is not notarized. The Board requires notarization for a custom authorization letter used in place of OC-110A, but the Board’s own form needs only your ink signature.⁴

Electronic signatures are not accepted. The Board does not accept them on prescribed forms as a standard practice, because it cannot efficiently verify that the electronic signature process complies with the New York Electronic Signatures and Records Act. If you type into a fillable PDF before printing, the Board recommends printing it to a new PDF using “Microsoft Print to PDF” first, because data entered in fillable fields sometimes fails to transmit and the Board receives a blank page.⁵

If your file contains HIV-related information, mental health records, or substance abuse treatment records, separate New York privacy laws apply and the Department of Health has its own authorization forms (DOH-2557 and DOH-5032) that may be required alongside or in place of OC-110A. Contact the Board before submitting if any of those categories are in your file.⁶

What the Authorization Does and Does Not Grant

OC-110A gets the recipient paper or electronic copies of the records. It does not open an eCase account for them or let them view your case through eCase outside of a Board location. The form states this explicitly.³

There is no automatic expiration. Once submitted, the authorization stays in effect indefinitely until you revoke it in writing. If you want a one-time release or a limited window, send a written revocation to the Board as soon as the records have been delivered. Revocation takes effect when the Board receives it and does not apply to records already released.³

How to Submit It

OC-110A must be submitted by U.S. Postal Service mail. The Board needs to verify the original signature, so email, web upload, and fax do not count. If you send it any other way, the Board will contact the sender and ask for the original by mail, which delays everything.¹

Mail the completed original to:

NYS Workers’ Compensation Board
PO Box 5205
Binghamton, NY 13902-5205⁷

Photocopy the signed original before you mail it. The form itself instructs you to “submit original to the Workers’ Compensation Board and retain a copy for your records.” Certified mail with return receipt gives you a delivery date to reference if you need to follow up.

After You Mail It

The Board does not publish a specific turnaround time. Processing depends on the completeness of the form and current workload. You can view what is in your own electronic file at any time through eCase, the Board’s read-only online portal.⁸ The Board’s general information line can confirm an authorization was received.

There is no fee to submit the authorization itself, but the form warns that “the requesting party may be required to pay a statutory fee prior to being provided copies of these records.” Under the Public Officers Law, agencies can charge 25 cents per page for copies up to 9 by 14 inches, or the actual cost of reproduction for larger or more complex records.⁹

The usual causes of delay are predictable:

No case number or accident date, so the Board cannot locate the file.
Missing or incomplete recipient name or address, so the Board has nowhere to send the records.
A typed, digital, or missing signature instead of an original ink signature.
Submission by email, upload, or fax, which triggers a callback asking for the paper original.

What the Recipient Can and Cannot Do With Your Records

Anyone who receives records through OC-110A is prohibited from passing them along to someone not otherwise entitled to see them. Section 110-a says so directly: it is unlawful for a person who has obtained Board records to disclose that information to an unauthorized person.²

Violating that rule, or obtaining records under false pretenses, is a Class A misdemeanor carrying a fine of up to $1,000 upon conviction. A court can also impose civil penalties of up to $500 for a first violation and up to $1,000 for each subsequent violation within a three-year period. The Attorney General can seek an injunction to stop ongoing violations without having to prove anyone was actually harmed.³

1
New York State Workers’ Compensation Board. How To Submit Claims-Related Forms and Documents to WCB
2
New York State Senate. New York Code 110-A – Confidentiality of Workers’ Compensation Records
3
New York State Workers’ Compensation Board. Claimant’s Authorization to Disclose Workers’ Compensation Records
4
New York State Workers’ Compensation Board. Revised Form OC-110AORD, Request for Judicial Order – Access to Case Files
5
New York State Workers’ Compensation Board. Workers’ Compensation Board Common Forms
6
New York State Department of Health. Authorization for Release and Complaint Forms
7
Workers’ Compensation Board. NYS WCB Contact Information
8
New York State Workers’ Compensation Board. eCase Overview
9
Workers’ Compensation Board. Request Workers’ Compensation Board Records Through the New York State Freedom of Information Law