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OCF-5 Permission To Disclose

This 3 sentence summary provides the key details from the given document: This form is used to disclose health information for automobile accident claims and allows the applicant to authorize their treating health professional to disclose relevant health information to their insurer. It collects information about the applicant, their insurance company, and treating health professional. The applicant must sign to consent to the disclosure of their health information relating to the accident and any pre-existing or subsequent conditions that could impact their recovery.

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Ravi Kaushik
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166 views1 page

OCF-5 Permission To Disclose

This 3 sentence summary provides the key details from the given document: This form is used to disclose health information for automobile accident claims and allows the applicant to authorize their treating health professional to disclose relevant health information to their insurer. It collects information about the applicant, their insurance company, and treating health professional. The applicant must sign to consent to the disclosure of their health information relating to the accident and any pre-existing or subsequent conditions that could impact their recovery.

Uploaded by

Ravi Kaushik
Copyright
© © All Rights Reserved
We take content rights seriously. If you suspect this is your content, claim it here.
Available Formats
Download as PDF, TXT or read online on Scribd
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Return this form to:

Permission to Disclose
Health Information (OCF-5)
Use this form for accidents that occur on or after January 1, 1994.
Collection, use and disclosure of this information is subject to all applicable
privacy legislation.

Claim Number:

Policy Number:
Date of Accident:
(YYYYMMDD)

Last Name First Name and Initial Date of year month day
Part 1 Accident
Applicant Address
Information
City Province Postal Code

Birth year month day Home Telephone Work Telephone Extension


Date

Name of Insurance Company


Part 2
Insurance Name of Insurance Company Representative
Company
Information
Address City

Province Postal Code Telephone Number FAX Number

Name of Health Professional Health Profession


Part 3
Treating Address
Health
Professional City Province Postal Code

Telephone Number FAX Number

I authorize my treating health professional to collect, use and disclose to my insurer or to a health professional,
Part 4 social worker, or vocational rehabilitation expert properly appointed by my insurer to conduct an examination,
Signature only such information relating to my health condition and treatment received as a result of the automobile
accident and any pre-existing or subsequently occurring health conditions that may be a barrier to my recovery
as a result of the automobile accident, as is reasonably required for the purpose of providing treatment and
determining my eligibility for benefits. This authorization is valid until my claim for Statutory Accident Benefits
has been concluded or until I withdraw this consent. (Please note withdrawal of this consent may impact your
benefit entitlement).

This authorization does not apply to a consultation between my health care provider and the insurer’s health
professional conducting an examination. Separate express consent is required for this consultation. This
consent should be in writing.

Name of Applicant or Substitute Decision Maker (please print) Signature of Applicant or Substitute Decision Maker Date (YYYYMMDD)

SAVE

Effective (2010-09-01) OCF–5

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