Fill and Sign the Authorization to Release Medical Information Bwc 1224pdf

Authorization to Release Medical Information Address Injured worker name (first, M.I., last) Employer name Date of injury State City 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: • 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. 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 Injured worker (or guardian or personal representative) signature Date Employer MCO or QHP . Instructions• Please print or type.• List the provider(s) you are authorizing to release medical records in the space i\ ndicated 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. You can obtain this form online at www.bwc.ohio.gov .