Form C-72 (BWC-1192) "Consent to Release Information" - Ohio

What Is Form C-72 (BWC-1192)?

This is a legal form that was released by the Ohio Bureau of Workers' Compensation - a government authority operating within Ohio. As of today, no separate filing guidelines for the form are provided by the issuing department.

Form Details:

  • Released on August 30, 2012;
  • The latest edition provided by the Ohio Bureau of Workers' Compensation;
  • Easy to use and ready to print;
  • Available in Spanish;
  • Quick to customize;
  • Compatible with most PDF-viewing applications;
  • Fill out the form in our online filing application.

Download a printable version of Form C-72 (BWC-1192) by clicking the link below or browse more documents and templates provided by the Ohio Bureau of Workers' Compensation.

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Download Form C-72 (BWC-1192) "Consent to Release Information" - Ohio

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Consent to Release Information
Instructions
 Use this form if you want BWC to release information we have about your claim with another individual or organization.
 This signed consent applies specifically to this claim. You must file a separate consent form for each additional BWC
claim you wish to release.
 If you need assistance, visit ohiobwc.com, or call BWC toll free at 1-800-OHIOBWC.
Injured worker
Injured worker name
Claim number
Date of birth
Phone number
Address
City
State
ZIP code
Information may include medical records, wages, compensation payments, allowed conditions and/or previous Industrial
Commission of Ohio hearing orders.
I authorize BWC to disclose documentation to the individual and/or organization listed below information regarding this
claim.
I authorize BWC to verbally communicate information about my claim with the individual listed below such as a family
member or union representative.
Release information to
Name and/or organization
Address
City
State
ZIP code
Phone number
By signing below, I represent that I have the authority to sign this document, and I acknowledge the following:
 I understand the information included in my health and medical records may include sensitive information related to
private health matters;
 I understand if HIV/AIDS is an allowed condition in my claim, my health and medical records may include information
related to these conditions. Based upon this specific allowance, you must enter an ending date below to indicate the
time this release will be effective, not to exceed 12 months from date of signature;
 I understand if a psychological condition is allowed in my claim, my health and medical records may include
information related to these conditions;
 I understand BWC does not control the use of the released information once it has been disclosed to a recipient; any
disclosure of information creates the potential for an unauthorized re-disclosure by the recipient; and that BWC
expressly denies any liability for any consequences arising out of such disclosure;
 I understand I have a right to revoke this consent, verbally or in writing, at any time;
 I understand I can refuse to sign this consent, and I further acknowledge that I have executed this consent voluntarily
and by my own free will.
This consent is valid until:
12 months from date of signature, or
Specific date ______/______/______.
Signature of injured worker (or legal guardian, authorized representative, or executor, where applicable)
Date
BWC-1192 (Rev. 8/30/2012)
C-72
Consent to Release Information
Instructions
 Use this form if you want BWC to release information we have about your claim with another individual or organization.
 This signed consent applies specifically to this claim. You must file a separate consent form for each additional BWC
claim you wish to release.
 If you need assistance, visit ohiobwc.com, or call BWC toll free at 1-800-OHIOBWC.
Injured worker
Injured worker name
Claim number
Date of birth
Phone number
Address
City
State
ZIP code
Information may include medical records, wages, compensation payments, allowed conditions and/or previous Industrial
Commission of Ohio hearing orders.
I authorize BWC to disclose documentation to the individual and/or organization listed below information regarding this
claim.
I authorize BWC to verbally communicate information about my claim with the individual listed below such as a family
member or union representative.
Release information to
Name and/or organization
Address
City
State
ZIP code
Phone number
By signing below, I represent that I have the authority to sign this document, and I acknowledge the following:
 I understand the information included in my health and medical records may include sensitive information related to
private health matters;
 I understand if HIV/AIDS is an allowed condition in my claim, my health and medical records may include information
related to these conditions. Based upon this specific allowance, you must enter an ending date below to indicate the
time this release will be effective, not to exceed 12 months from date of signature;
 I understand if a psychological condition is allowed in my claim, my health and medical records may include
information related to these conditions;
 I understand BWC does not control the use of the released information once it has been disclosed to a recipient; any
disclosure of information creates the potential for an unauthorized re-disclosure by the recipient; and that BWC
expressly denies any liability for any consequences arising out of such disclosure;
 I understand I have a right to revoke this consent, verbally or in writing, at any time;
 I understand I can refuse to sign this consent, and I further acknowledge that I have executed this consent voluntarily
and by my own free will.
This consent is valid until:
12 months from date of signature, or
Specific date ______/______/______.
Signature of injured worker (or legal guardian, authorized representative, or executor, where applicable)
Date
BWC-1192 (Rev. 8/30/2012)
C-72