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Disclosure authorization form – Ohio Rev. Code Ann. § 3904.06

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An insurance institution, agent, or insurance support organization must use a disclosure authorization form for the disclosure of personal or privileged information about an individual in connection with insurance transactions that meets the following qualifications:

  • Is written in plan language;
  • Specifies the types of persons authorized to disclose information about the individual;
  • Specifies the nature of the information authorized to be disclosed;
  • Names the insurance institution or agent and identifies representatives of the institution to whom the individual is authorizing information to be disclosed;
  • Specifies the purpose for which the information is collected; and
  • Specifies the length of time such authorization will remain valid.

Current as of June 2015