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Authorization form – Ohio Rev. Code Ann. § 5101.272

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For the purposes of disclosing medical assistance information, an authorization must be made on a form that uses language understandable to the average person and contains all the following:

  • A description of the information to be used or disclosed;
  • Identification of the person or class of persons authorized to make the requested use or disclosure;
  • Identification of the person or governmental entity to which the information may be released; and
  • A description of each purpose of the requested use or disclosure of the information. 

Current as of June 2015