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Blank Ohio Bwc 1389 PDF Form

The Ohio BWC 1389 form is an authorization document that allows the Bureau of Workers' Compensation (BWC) to share information about an injured worker with designated individuals, such as family members or caregivers. This form is essential for those who need assistance in managing their claims or obtaining necessary information from the BWC. To ensure your information is shared appropriately, consider filling out the form by clicking the button below.

Article Guide

The Ohio Bureau of Workers' Compensation (BWC) 1389 form serves a crucial purpose in facilitating communication between injured workers and their support networks. This form allows individuals to authorize the BWC to share pertinent information regarding their claims with designated persons, such as family members, friends, or caregivers. By filling out the BWC 1389, injured workers can ensure that those who assist them in navigating the complexities of workers' compensation have access to essential details. The authorization is valid for one year from the date of signature, providing a clear timeframe for when this consent is active. Key components of the form include personal identification details, such as the worker's name, date of birth, and claim number, as well as the names and contact information of those authorized to receive information. Importantly, the form specifies what types of information can be shared, including claims status, medical documentation, and wage or payment details. By understanding the BWC 1389 form and its implications, injured workers can better manage their claims and ensure that their support systems are informed and engaged in the process.

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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
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

➤ PDF File

Form Specifications

Fact Name	Details
Purpose of the Form	This form allows individuals to authorize the Ohio Bureau of Workers' Compensation (BWC) to share their information with designated persons.
Validity Period	The authorization granted by this form is valid for one year from the date it is signed.
Eligible Recipients	Information can be shared with family members, friends, caregivers, or anyone assisting with BWC forms.
Required Information	To complete the form, individuals must provide their name, date of birth, claim number, and address.
Signature Requirement	The injured worker, or their guardian or personal representative, must sign the form to authorize the release of information.
Information Types	Authorized information may include claims status, medical documentation, and details about wages or payments.
Governing Law	The use of this form is governed by Ohio Revised Code Section 4123.88, which pertains to the confidentiality of workers' compensation information.
Additional Instructions	If signed by a guardian or representative, a description of their authority to act on behalf of the injured worker must be provided.
Form Revision Date	The current version of the BWC-1389 form was revised on March 18, 2009.
Contact Information	Individuals must provide contact details for both themselves and the person to whom the information will be released, including phone and fax numbers.

Ohio Bwc 1389: Usage Guidelines

Filling out the Ohio BWC 1389 form is a straightforward process. Once completed, this form allows the Bureau of Workers' Compensation (BWC) to share your information with designated individuals. Make sure to have all necessary information ready before you start.

Begin by writing your name in the designated field at the top of the form.
Next, enter your date of birth in the provided space.
Fill in your claim number accurately.
Write your address, including street, city, state, and nine-digit ZIP code.
Indicate the name and relationship of the person you want to authorize to receive your information.
Provide the address for the authorized person, including city, state, and ZIP code.
Fill in the phone number and fax number for the authorized person.
Select the specific information you want to authorize BWC to release by checking the appropriate boxes (claims status, medical documentation, wages/payments, or all).
Sign the form where it states injured worker (or guardian or personal representative) signature.
Finally, if someone other than you is signing, provide a brief description of their authority to sign on your behalf.

Your Questions, Answered

What is the purpose of the Ohio BWC 1389 form?

The Ohio BWC 1389 form, also known as the Authorization to Release Information, allows individuals to grant permission for the Bureau of Workers' Compensation (BWC) to share their personal information with designated individuals. This can include family members, friends, caregivers, or anyone who assists in completing BWC forms. The authorization is valid for one year from the date it is signed.

Who can I authorize to receive my information using this form?

You can authorize anyone you trust to receive your information. This can be a family member, a close friend, or a caregiver. It is important to specify the relationship to ensure that BWC understands the context of the authorization. The form requires you to provide the name, address, and contact details of the person you wish to designate.

What types of information can be released through the Ohio BWC 1389 form?

The form allows you to specify the type of information that can be shared. This includes claims status, medical documentation, and details about wages or payments. By clearly indicating what information you authorize to be released, you can ensure that the designated person receives only the relevant details they need to assist you.

How long is the authorization valid?

The authorization granted through the Ohio BWC 1389 form is valid for one year from the date you sign it. If you need to extend this authorization or wish to change the individuals authorized to receive your information, you will need to complete a new form. Always keep track of the expiration date to ensure that your designated individuals can continue to access your information as needed.

Common mistakes

Failing to include the claim number. This number is crucial for BWC to identify your case.
Not providing a valid signature. Ensure that the signature matches the name on the form.
Leaving out the date of birth. This information helps verify your identity.
Forgetting to specify the relationship of the person receiving the information. This detail is important for clarity.
Not including a phone number for the person authorized to receive information. This may delay communication.
Neglecting to indicate the specific information that can be shared. Be clear about what details you want released.
Using an expired authorization. Remember, this form is only valid for one year from the date you sign it.
Failing to provide a description of the guardian or representative’s authority if they are signing on behalf of the injured worker. This is necessary for verification.
Not double-checking the address information. An incorrect address can lead to issues with communication.

Documents used along the form

The Ohio BWC 1389 form is essential for individuals seeking to authorize the Bureau of Workers' Compensation (BWC) to share their information with designated persons. Several other forms and documents often accompany this form to facilitate various aspects of the claims process. Below are some commonly used documents.

BWC 1 - This is the First Report of Injury form. It is used to notify the BWC about a workplace injury or illness. This form must be completed promptly to ensure timely processing of claims.
BWC 2 - The BWC 2 form is the Employer's Report of Injury. Employers use this form to report injuries that occur at the workplace. Accurate information helps in the management of claims.
BWC 3 - This form is the Employee's Claim for Compensation. Injured workers must complete it to file a claim for benefits. It includes details about the injury, medical treatment, and employment history.
BWC 7 - The BWC 7 form is the Application for Permanent Total Disability Benefits. This document is used by injured workers seeking long-term benefits due to permanent disabilities resulting from work-related injuries.
BWC 11 - This is the Notice of Appeal form. If a claim is denied or benefits are reduced, this form allows injured workers to formally appeal the decision made by the BWC.
BWC 12 - The BWC 12 form is the Request for Reimbursement. Employers can use this form to request reimbursement for certain medical costs related to workplace injuries.

Understanding these forms and their purposes can significantly enhance the claims process for injured workers and their representatives. Properly completing and submitting these documents ensures that individuals receive the benefits they are entitled to in a timely manner.

Similar forms

The Ohio BWC 1389 form, which is used to authorize the release of personal information from the Bureau of Workers' Compensation, has similarities with several other documents that serve similar purposes. Below is a list of seven documents that share characteristics with the BWC 1389 form:

HIPAA Release Form: This document allows healthcare providers to share an individual's medical information with specified third parties. Like the BWC 1389, it requires the individual’s consent and has a limited validity period.
Power of Attorney: A power of attorney grants someone the authority to act on another person's behalf in legal or financial matters. Similar to the BWC 1389, it involves the individual’s consent and can specify the types of decisions the designated person can make.
Authorization for Release of Educational Records (FERPA): Under the Family Educational Rights and Privacy Act, this form allows students to authorize the release of their educational records. It shares the same intent of protecting personal information while allowing access to designated individuals.
Consent to Release Information for Social Security Disability: This form permits the Social Security Administration to share information with other parties involved in a disability claim. Like the BWC 1389, it is focused on specific information and requires the claimant's signature.
Release of Liability Form: Often used in various contexts, this document releases a party from liability in exchange for certain information or services. It shares the element of consent, as individuals must agree to the terms before any information is disclosed.
Medical Release Form: This form is often used in medical settings to allow healthcare providers to share patient information with other medical professionals or family members. It mirrors the BWC 1389 in its focus on medical documentation and the need for patient consent.
Authorization for Release of Information in Workers' Compensation Claims: Similar to the BWC 1389, this document allows injured workers to authorize the release of their claim information to various parties involved in their case. It emphasizes the importance of consent and specifies the information to be shared.

Dos and Don'ts

When filling out the Ohio BWC 1389 form, it is essential to approach the task with care. Below are some guidelines that can help ensure the process goes smoothly.

Do read the entire form carefully before starting to fill it out.
Do provide accurate and complete information, including your name, date of birth, and claim number.
Do ensure that the person you are authorizing to receive information is clearly identified.
Don't forget to sign and date the form; your signature is crucial for validation.
Don't leave any required fields blank; incomplete forms may delay processing.
Don't use outdated information; remember that the authorization is valid for only one year from the date of your signature.

By following these guidelines, you can help facilitate the process of sharing important information with the designated individuals. Properly completing the form not only aids in communication but also ensures that your rights and interests are protected.

Misconceptions

Understanding the Ohio Bureau of Workers' Compensation (BWC) 1389 form can be challenging. Here are nine common misconceptions about this important document, along with clarifications to help you navigate the process.

The BWC 1389 form is only for medical professionals. Many believe this form is exclusively for healthcare providers. In reality, it allows anyone, including family members and friends, to receive information about a claim.
Once I sign the form, I can never revoke it. Some think that signing the BWC 1389 is a permanent decision. However, you can revoke the authorization at any time before it expires.
This form is valid indefinitely. A common misconception is that the authorization lasts forever. The truth is, it is only valid for one year from the date you sign it.
Only the injured worker can fill out this form. Many assume that only the injured party can complete the BWC 1389. However, guardians or personal representatives can also sign on behalf of the injured worker.
I don’t need to specify what information can be released. Some individuals think they can simply authorize any information without specifying. In fact, you must indicate what specific information you want to be shared.
The BWC 1389 form is only for claims status updates. While many believe this form is limited to claims status, it can also authorize the release of medical documentation and wage information.
My information is automatically shared with anyone I authorize. It’s a common misunderstanding that simply naming someone on the form allows for automatic sharing. BWC will only release information after verifying the authorization.
There’s no need to provide my relationship to the person I’m authorizing. Some think that relationship details are unnecessary. However, stating your relationship helps clarify the context of the authorization.
The form is not necessary if I’m using an attorney. Many believe that having an attorney means they don’t need to fill out the BWC 1389. However, your attorney may still need specific authorization to access certain information on your behalf.

By understanding these misconceptions, you can better navigate the BWC process and ensure that the right people have access to the information they need.

Key takeaways

Here are key takeaways about filling out and using the Ohio BWC 1389 form:

Purpose of the Form: This form allows the Bureau of Workers' Compensation (BWC) to share your information with designated individuals.
Who Can Be Authorized: You can authorize family members, friends, caregivers, or anyone who assists you with BWC forms.
Validity Period: The authorization is valid for one year from the date you sign the form.
Required Information: You need to provide your name, date of birth, claim number, and address.
Designating Contacts: Clearly list the names and relationships of individuals you authorize to receive your information.
Types of Information Shared: You can specify what information you want to be shared, such as claims status, medical documentation, or wage details.
Signature Requirement: The form must be signed by you or your guardian/personal representative, along with a description of their authority if applicable.