The Ohio BWC 1389 form is an authorization document that allows the Bureau of Workers' Compensation (BWC) to share your personal information with designated individuals. This could include family members, friends, or caregivers who assist you with your claims or other related matters. Remember, this authorization remains valid for one year from the date you sign it.
The Ohio Bureau of Workers' Compensation (BWC) 1389 form serves an important function for individuals seeking assistance with their workers' compensation claims. This form allows claimants to authorize the BWC to share their personal information with designated individuals, such as family members, friends, or caregivers. By completing this form, claimants can ensure that those who are helping them navigate the complexities of the BWC system have access to relevant information. The authorization provided through this form is valid for one year from the date it is signed, which means that individuals should be mindful of the expiration date when seeking assistance. The form requires basic personal details, including the claimant's name, date of birth, and claim number, as well as the names and contact information of the individuals authorized to receive information. Specific types of information that can be shared include claims status, medical documentation, and details about wages or payments. For those who may not be able to sign the form themselves, provisions are made for guardians or personal representatives to do so, provided they can describe their authority to act on behalf of the injured worker. Understanding the purpose and requirements of the BWC 1389 form can help individuals better manage their claims and ensure that they receive the support they need.
AUTHORIZATION TO RELEASE
INFORMATION
USE THIS FORM IF you want BWC to share the information we have about you with another person such as:
•A family member, friend or other relative;
•Someone who helps take care of you;
•Someone who helps you ill out BWC forms.
This authorization is only valid for one year from date of signature.
Name
Date of birth
Claim number
Address
City
State
Nine-digit ZIP code
I authorize BWC to release information to the person named
below.
Name/relationship
And/or
City, State, ZIP code
Phone number
Fax number
Specific information authorized
Claims status
Other
Medical documentation
Wages/payments
All
Injured worker (or guardian or personal representative) signature
Date
If signed by the injured worker's guardian or personal representative, provide here a description of the guardian
or personal representative’s authority to sign on behalf of the injured worker.
.
BWC-1389 (Rev. 3/18/2009)
C-257
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