Authorization To Release Medical Information - Ohio Bwc printable pdf download

Authorization to Release

Medical Information

Instructions

You can obtain this form online at

• Please print or type.

• List the provider(s) you are authorizing to release medical records in the space indicated on this form.

• Please sign and date the form, and send it to the customer service office where your claim is located or to your self-insured employer.

Injured worker name (first, M.I., last)

Date of injury

Claim number

Address

City

State

Nine-digit ZIP code

Employer name

Employer MCO or QHP

I, the above-named injured worker, understand I am allowing the Opportunities for Ohioans with Disabilities and the

providers (persons or facilities) named here (_________________________________________________________________

_____________________________________________________________________________________) that attend or examine

me to release the following medical, psychological and/or psychiatric information (excluding psychotherapy notes)

that are related causally or historically to physical or mental injuries relevant to my workers’ compensation claim:

• Pathology slides and immunohistochemical staining results, if applicable;

•

Hospital admission history and physical; emergency room reports; hospital discharge summaries; physician

office notes; physical therapist, occupational therapist or athletic trainer assessments and progress notes;

consultation reports; lab results; medical reports; surgical reports; diagnostic reports; procedure reports; nurs-

ing home and skilled nursing facilities documentation; home nursing progress notes; or other listed below.

____________________________________________________________________________________________________

I understand I am authorizing the release of this information to the following: the Ohio Bureau of Workers’ Com-

pensation (BWC), the Industrial Commission of Ohio, the above-named employer, the employer’s managed care

organization or qualified health plan and any authorized representatives.

I understand this information is being released to the above-referenced persons and/or entities for use in administering

my workers’ compensation claim.

This authorization to release medical, psychological and/or psychiatric information shall remain in effect for as

long as my workers’ compensation claim remains open under Ohio law. I understand I have the right to revoke this

authorization at any time. However, I must submit my revocation in writing and file it with BWC or my self-insured

employer. My decision to revoke this authorization will be effective, except in the case that any provider referenced

above already has relied on my authorization and released information.

I understand the provider(s) referenced above may not make my completing and signing this authorization a condition

of my treatment.

I understand the parties I am authorizing the release of information to are exempted from the federal privacy require-

ments of the Health Insurance Portability and Accountability Act of 1996 as they administer workers’ compensation

programs. Information disclosed pursuant to this authorization may be redisclosed by them and may no longer be

protected by the federal privacy requirements. I understand such redisclosures may include but are not limited to

the following:

• A copy of the medical information the employer receives may be forwarded to BWC by the employer;

• A copy of the medical information will be available to me or my physician of record upon request to BWC or

to the employer.

Injured worker (or guardian or personal representative) signature

Date

If signed by the injured worker's guardian or personal representative, provide a description of the guardian

or personal representative’s authority to sign on behalf of the injured worker. __________________________________

__________________________________

___________________________________________________________________________________________________________

BWC-1224 (Rev. 9/24/2013)

C-101

Authorization To Release Medical Information - Ohio Bwc

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