Ohio Bwc 1389 Form Modify Form Here

Ohio Bwc 1389 Form

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.

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Table of Contents

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.

Form Sample

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

 

I authorize BWC to release information to the person named

below.

 

 

below.

 

Name/relationship

 

 

Name/relationship

 

 

 

And/or

 

 

Address

 

Address

 

 

 

 

 

City, State, ZIP code

 

City, State, ZIP code

 

 

 

 

 

 

 

 

 

Phone number

Fax number

 

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

Form Information

Fact Name Description
Purpose of the Form The BWC 1389 form allows individuals to authorize the Ohio Bureau of Workers' Compensation (BWC) to share their information with designated persons.
Valid Duration This authorization remains valid for one year from the date of the signature.
Who Can Be Authorized Individuals can authorize family members, friends, caregivers, or anyone assisting with BWC forms.
Information Shared The form allows for the release of various types of information, including claims status, medical documentation, and wage/payment details.
Signature Requirement The injured worker or their guardian/personal representative must sign the form to authorize the release of information.
Guardian Authority If a guardian or personal representative signs, they must provide a description of their authority to act on behalf of the injured worker.
Claim Number The form requires the inclusion of the claim number, which identifies the specific workers' compensation case.
Personal Information Individuals must provide personal information such as name, date of birth, address, and ZIP code on the form.
Governing Law This form is governed by the Ohio Revised Code, specifically sections related to workers' compensation and privacy regulations.
Form Revision Date The current version of the BWC 1389 form was revised on March 18, 2009.
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