Authorization For Release Of Retirement Account Information Form - Ohio

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AUTHORIZATION FOR RELEASE OF RETIREMENT
ACCOUNT INFORMATION
This form should be completed and provided to STRS Ohio to authorize STRS Ohio to release confidential information as
described below. Please allow three weeks for copying or certification of records. Medical reports and recommendations will
be sent by mail only. If you have questions as you complete this form, an STRS Ohio member service representative will be
happy to assist you — just call toll-free 1-888-227-7877.
Release of personal information (not including medical information)
Sections 1 and 2 must be completed to authorize release of personal information described below to an authorized agent or
attorney.
Section 3307.20 of the Revised Code and Administrative Code Rule 3307-1-03 specifically prohibit the release of any part of
a member’s or benefit recipient’s personal history record including the following information to a “third party” unless written
authorization is provided by the member or benefit recipient:
Any record identifying the amount of a benefit paid or payable to any person or the account balance;
Any record identifying the service history or service credit of a member, benefit recipient or the dependents or
beneficiaries of a member or benefit recipient; and
Any record that includes a member’s or benefit recipient’s address, email address, phone number, Social Security
number or correspondence with STRS Ohio.
Release of medical reports and recommendations
Sections 1, 2 and 3 must be completed to authorize release of medical reports and recommendations to a personal physician,
attorney or authorized agent. If you would like medical reports and recommendations to be sent to an authorized agent, the
agent must also provide a signed letter stating they accept the responsibility of receiving your medical information.
Medical reports and recommendations obtained by STRS Ohio for the purpose of determining disability or survivor benefits
under Sections 3307.48, 3307.62 or 3307.66, R.C., are privileged, except that copies of such medical reports and recommen-
dations shall be made available to the member’s or individual’s personal physician, attorney or authorized agent, upon written
release by the member or individual. No medical report or recommendation shall be released to the individual concerned.
Section 1 — General Information
Member’s or individual’s name___________________________________________________________________________
Address _____________________________________________________________________________________________
Member’s Social Security number or STRS Ohio account number _______________________________________________
Email address ________________________________________________________________________________________
I authorize the person(s) named in Section 2 to make inquiry and receive personal information regarding my retirement
account. This authorization will automatically expire six months from the date this form was signed OR on an earlier date
which I have provided here _____________________________.
Provide earlier expiration date.
I understand that if I wish to extend the authorization beyond a six-month period, I must complete and provide a new authori-
zation form to STRS Ohio.
I understand that Section 3307.20, R.C., permits medical reports and recommendations to be released only to a physician
assigned by the State Teachers Retirement Board or, upon my written authorization, to my personal physician, attorney or
authorized agent.
____________________________________________________________
_______________________________
Member’s signature
Date
(continued)
40-121, 8/13/2M

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