Authorization to Release
You can obtain this form online at ohiobwc.com
• 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)
Date of injury
Nine-digit ZIP code
Employer MCO or QHP
I, the above-named injured worker, understand I am allowing the Ohio Rehabilitation Services Commission 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 o