Authorization For Release Of Retirement Account Information Form - Ohio Page 2

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Section 2 — Release of Information
q
q
q
Personal physician
Attorney
Authorized agent
Name ______________________________________________________________ Title ___________________________
QDRO Consultants Co. / Pension Evaluators
Address _____________________________________________________________________________________________
3071 Pearl Rd, Medina, Ohio 44256
Phone (_________) __________________________________
Fax (_________) _________________________________
800
527-8481
330
722-2735
Area code
Area code
q
q
q
Personal physician
Attorney
Authorized agent
Name ______________________________________________________________ Title ___________________________
Address _____________________________________________________________________________________________
Phone (_________) __________________________________
Fax (_________) _________________________________
Area code
Area code
q
q
q
Personal physician
Attorney
Authorized agent
Name ______________________________________________________________ Title ___________________________
Address _____________________________________________________________________________________________
Phone (_________) __________________________________
Fax (_________) _________________________________
Area code
Area code
Section 3 — Release of Medical Information
If medical reports and recommendations under Sections 3307.48, 3307.62 or 3307.66, R.C., are to be released to your
physician, attorney or authorized agent, one of the following options must be selected.
q
By checking this box, I authorize STRS Ohio to release to the person(s) listed in Section 2, all medical reports and
recommendations under Sections 3307.48, 3307.62 or 3307.66, R.C.
q
By checking this box, I authorize STRS Ohio to release to the person(s) listed in Section 2, all disability correspondence
related to my current disability application or disability reexamination process.
q
By checking this box, I authorize STRS Ohio to release to the person(s) listed in Section 2, the specific medical reports
and recommendations under Sections 3307.48, 3307.62 or 3307.66, R.C., listed below. List the date of the examination
and the name of the STRS Ohio-appointed physician(s) whose reports and recommendations are to be released.
PHYSICIAN’S NAME
EXAMINATION DATE
__________________________________________________________
________________________________
__________________________________________________________
________________________________
__________________________________________________________
________________________________
__________________________________________________________
________________________________
__________________________________________________________
________________________________
40-121, 8/13/2M

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