Division of Administration and Finance Planning + Design + Construction PO Box 210186 Cincinnati, Ohio 45221-0186
INDUSTRIAL COMMISSION OF OHIO BUREAU OF WORKERS COMPENSATION Claim Number: Date of Injury: Claimant’s Name: Social Security Number: Employers Name: Allowed Condition(s):
AUTHORIZATION FOR RELEASE OF MEDICAL INFORMATION
Requested Condition(s):
As provided by Section 4123.651 (C) of the Ohio Revised Code, I hereby permit the release of medical information, records and reports relative to the issues necessary for the administration of my workers compensation claim to the Industrial Commission of Ohio, Ohio Bureau of Workers Compensation, or the employer as such medical information, records and reports pertain to a condition either allowed or requested in my claim, or to consider the payment or to determine the eligibility of payment of compensation and medical benefits under my workers compensation claim.
Signature of Claimant
OIC-0160 (Rev. 9/87)
Date
A copy of this shall be as valid as the original.
The above signature authorizes the physicians, hospitals and all medical attendants to furnish full and complete medical reports of the above named claimant to AIK SELECTIVE SELF-INSURANCE FUND, its agents or representatives, any third party administrator for the employer or the employer, with respect to any illness or injury, medical history, psychiatric treatment, consultation, prescription or treatment, including X-ray plates, and copies of all hospital records. THIS IS NOT A RELEASE OF ANY CLAIM I MAY HAVE.
cc: University Project Administrator File 0031A
Authorization for Release of Medical Information
Rev 6/2002