Ohio Medical Records Release Form 1
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Authorization to Release
Medical Information
Instructions
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)
Address

Claim number

Date of injury
City

Employer name

State

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