Authorization form – Ohio Rev. Code Ann. § 5101.272

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.