Authorization to Release Medical Information (C - Ohio BWC 2026

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The document is an 'Authorization to Release Medical Information' form for injured workers in Ohio, allowing them to authorize medical providers to release relevant medical records related to their work-related injuries. It outlines the necessary steps for completion, including listing providers, signing the form, and submitting it to the appropriate office. The form complies with HIPAA requirements while noting that the Bureau of Workers' Compensation (BWC) is exempt from these regulations. It also explains the rights of the injured worker regarding revocation of authorization and potential redisclosure of information.

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Click ‘Get Form’ to open it in the editor.
Begin by entering your name, including your first name, middle initial, and last name in the designated fields.
Fill in your address, including city, state, and nine-digit ZIP code.
Provide the date of your injury and the name of your employer.
Enter your claim number and the name of your employer's managed care organization (MCO) or qualified health plan (QHP).
In the section for authorized providers, list all medical professionals you are allowing to release information related to your claim.
Review the types of medical information you are authorizing for release. Ensure that all relevant documents are included.
Sign and date the form at the bottom. If applicable, provide details about any guardian or representative signing on your behalf.
Submit the completed form to the appropriate customer service office or self-insured employer as instructed.

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What does it mean to authorize the release of medical information?

HIPAA authorization is consent obtained from a patient or health plan member that permits a covered entity or business associate to use or disclose PHI to an individual/entity for a purpose that would otherwise not be permitted by the HIPAA Privacy Rule.

How do you write an authorization letter for medical records release?

I, the undersigned, authorize the release of, or request access to the information specified below from the medical record(s) of the above name patient. I understand that my records are confidential and cannot be disclosed without my written authorization, except when otherwise permitted by law.

How to fill out authorization to release information?

Begin by specifying your name, the entity authorized to disclose information, and the individuals or entities you authorize to receive it. Indicate the specific information and purpose for which it will be disclosed, add an expiration date or event, and sign and date the form to confirm your consent.

How to fill out an authorization letter?

How do I write a simple letter of authorization? Start with your name and contact information at the top. Include the current date. Write the recipients name and contact information. Clearly state your name and that youre writing to grant authorization to another individual or organization.