Fill and Sign the Fillable Online Bwc State Oh Authorization of Representative of Form

Claima nt Authorized Representative BWC -6102 (Rev. Oct. 26 , 2016 ) R-2 Complete this form in its entirety and fax it to 1 -866 -336 -8352, or send it to the BWC customer service offic e where your claim is assigned. The form is available online at www.bwc.ohio.gov . Claimant information Claimant name Date of injury Claim number Claimant address City State ZIP code Email address, if available Phone number Representative information *You may have only one legal representative (one attorney or one law firm) and one union representative . **Your representative must have a BWC representative identification number prior to being designated as an authorized representative . Representative/F irm n ame* Representative BWC ID number** Phone number Representative street address City State ZIP co de Authorization I authorize the above to be my authorized representative. The authorization entitles the representative access to my complete claim file, including medical and/or other information contained therein, and to receive correspondence genera ted in the above claim. I further understand that:  If I designate an attorney or law firm, BWC will remove any previously designated attorney or law firm as legal authorized representative, and it is my responsibility to notify the former legal representat ives of the change;  If I have previously authorized an individual in this claim to receive my workers’ compensation check, I understand that, if desired, I must cancel the previous aut horization separately in writing. The authorization above is being gi ven to a: Attorney Law f irm Union r epresentative Other (P lease explain .) Signature of claimant Printed name Date of authorization