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Preview - Ohio Bwc 1389 Form

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

Document Properties

Fact Name Description
Purpose The BWC 1389 form allows individuals to authorize the Ohio Bureau of Workers' Compensation (BWC) to share their personal information with designated individuals.
Validity Period This authorization remains valid for one year from the date the form is signed.
Eligible Recipients Information can be shared with family members, friends, caregivers, or anyone assisting in completing BWC forms.
Required Information To complete the form, individuals must provide their name, date of birth, claim number, and address details.
Governing Law The use of the BWC 1389 form is governed by Ohio Revised Code Section 4123.88, which pertains to the confidentiality of workers' compensation records.

Documents used along the form

When dealing with the Ohio BWC 1389 form, several other forms and documents may also be necessary. These documents help streamline the process of managing claims and ensure that all parties have the necessary information. Below is a list of commonly used forms that you might encounter alongside the BWC 1389.

  • Ohio BWC 1 Form: This is the initial application for workers' compensation benefits. It provides basic information about the injured worker and the details of the injury.
  • California Motorcycle Bill of Sale: This form is essential for transferring ownership of a motorcycle, protecting both the buyer and seller. For more information, visit https://documentonline.org/blank-california-motorcycle-bill-of-sale.
  • Ohio BWC 2 Form: This form is used to report the details of the injury to the Bureau of Workers' Compensation. It includes information about the nature of the injury and the circumstances surrounding it.
  • Ohio BWC 3 Form: This is the wage statement form. It details the injured worker’s earnings and is crucial for determining compensation benefits.
  • Ohio BWC 4 Form: This form is used for requesting a hearing if there is a dispute regarding the claim. It allows the injured worker to formally contest decisions made by the BWC.
  • Ohio BWC 5 Form: This is a medical release form that allows healthcare providers to share the injured worker's medical information with the BWC, which is necessary for processing claims.

Understanding these forms can help you navigate the workers' compensation process more effectively. Each document plays a vital role in ensuring that claims are handled properly and that the injured worker receives the benefits they deserve.

Guidelines on Filling in Ohio Bwc 1389

Completing the Ohio BWC 1389 form is a straightforward process. This form allows you to authorize the Bureau of Workers' Compensation (BWC) to share your information with designated individuals. Ensure that you have all necessary information at hand before starting. Follow the steps below to fill out the form accurately.

  1. Begin by entering your name in the designated field at the top of the form.
  2. Provide your date of birth in the specified format.
  3. Fill in your claim number, which you can find in your BWC correspondence.
  4. Enter your address, including street, city, state, and nine-digit ZIP code.
  5. In the section for authorized individuals, write the name and relationship of the person you wish to authorize.
  6. Provide the address of the authorized person, including city, state, and ZIP code.
  7. Fill in the phone number and fax number for the authorized individual.
  8. Specify the information you want to authorize for release, such as claims status, medical documentation, or wages/payments.
  9. Sign the form in the space provided, indicating your status as the injured worker, guardian, or personal representative.
  10. If applicable, describe the authority of the guardian or personal representative to sign on behalf of the injured worker.
  11. Finally, write the date when you signed the form.

Once you have completed the form, ensure that all information is accurate. Submit it to the appropriate BWC office to facilitate the sharing of your information with the authorized individuals. Keep a copy for your records.

Common mistakes

Filling out the Ohio BWC 1389 form can be straightforward, but many people make common mistakes that can lead to delays or complications. One frequent error is not providing complete information. For instance, leaving out your date of birth or claim number can result in the form being rejected. Each piece of information is essential for the Bureau of Workers' Compensation (BWC) to process your request efficiently.

Another mistake is failing to specify the relationship of the person to whom you are authorizing information release. Without this detail, the BWC may not understand the context of the request. Clearly stating whether the individual is a family member, friend, or caregiver helps clarify the situation.

Many individuals also overlook the importance of the signature. If the injured worker is unable to sign, the guardian or personal representative must provide their signature along with an explanation of their authority. Neglecting this step can render the form invalid.

Some people may mistakenly think they can authorize the release of information indefinitely. However, the authorization is only valid for one year from the date of signature. Failing to renew the authorization can lead to gaps in communication and access to necessary information.

Additionally, it is crucial to double-check the contact information for the person receiving the information. Providing incorrect phone numbers or addresses can delay the process and lead to misunderstandings. Ensuring accuracy in this section is vital for effective communication.

Lastly, many individuals do not specify the type of information they wish to be shared. The form allows you to select specific categories, such as claims status or medical documentation. Omitting this detail can lead to confusion about what information is being requested, potentially hindering the support you receive.

FAQ

  1. What is the purpose of the Ohio BWC 1389 form?

    The Ohio BWC 1389 form, also known as the Authorization to Release Information, allows you to grant permission to the Bureau of Workers' Compensation (BWC) to share your information with another individual. This could include a family member, friend, or anyone assisting you with your BWC-related matters.

  2. Who can I authorize to receive my information?

    You can authorize anyone you trust, such as a family member, friend, or caregiver. This person may help you manage your claims, fill out forms, or simply stay informed about your case.

  3. How long is the authorization valid?

    The authorization you provide on this form is valid for one year from the date you sign it. After one year, you will need to submit a new form if you wish to continue sharing your information.

  4. What specific information can be released?

    You can specify what information you want BWC to share. This may include:

    • Claims status
    • Medical documentation
    • Wages and payments

  5. What information do I need to provide on the form?

    When filling out the form, you will need to provide:

    • Your name
    • Date of birth
    • Claim number
    • Your address, including city, state, and ZIP code
    • The name and relationship of the person you are authorizing
    • Their address and contact information

  6. What if I am signing on behalf of someone else?

    If you are signing the form as a guardian or personal representative, you must provide a description of your authority to act on behalf of the injured worker. This ensures that BWC understands your role in the process.

  7. How do I submit the completed form?

    Once you have completed the form, you can submit it directly to the BWC. Make sure to keep a copy for your records. You may need to follow up to ensure that the authorization has been processed.

  8. What should I do if I change my mind?

    If you decide you no longer want to authorize someone to receive your information, you can revoke the authorization. To do this, you may need to submit a written request to the BWC stating your intention to withdraw the authorization.