Authorization to Release Medical Information Instructions You can obtain this form online at www.bwc.ohio.gov · 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) Address Employer name City Employer MCO or QHP Date of injury State Claim number Nine-digit ZIP code 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: · Pathologyslidesandimmunohistochemicalstainingresults,ifapplicable; · Hospitaladmissionhistoryandphysical;emergencyroomreports;hospitaldischargesummaries;physician officenotes;physicaltherapist,occupationaltherapistorathletictrainerassessmentsandprogressnotes; consultationreports;labresults;medicalreports;surgicalreports;diagnosticreports;procedurereports;nursinghomeandskillednursingfacilitiesdocumentation;homenursingprogressnotes;orotherlistedbelow. ____________________________________________________________________________________________________ . I understand I am authorizing the release of this information to the following: the Ohio Bureau of Workers' Compensation (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 requirements 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: · AcopyofthemedicalinformationtheemployerreceivesmaybeforwardedtoBWCbytheemployer; · AcopyofthemedicalinformationwillbeavailabletomeormyphysicianofrecorduponrequesttoBWCor 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 American LegalNet, Inc. www.FormsWorkFlow.com