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Get US OCF-5 2010-2024

Return this form to Permission to Disclose Health Information OCF-5 Use this form for accidents that occur on or after January 1 1994. Name of Applicant or Substitute Decision Maker please print Signature of Applicant or Substitute Decision Maker Date YYYYMMDD SAVE Effective 2010-09-01 FSCO 1225E OCF 5 Page 1 of 1. Collection use and disclosure of this information is subject to all applicable privacy legislation* Claim Number Policy Number Date of Accident YYYYMMDD Part 1 Applicant Information Last Name First Name and Initial Birth Date Province year month day Postal Code Work Telephone Home Telephone Extension Name of Insurance Company Representative Address City FAX Number Telephone Number Name of Health Professional Health Profession Part 4 Signature Part 3 Treating Health Professional Part 2 Insurance Company Date of Accident I authorize my treating health professional to collect use and disclose to my insurer or to a health professional social worker or vocational rehabilitation expert properly appointed by my insurer to conduct an examination 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 consent should be in writing. Collection use and disclosure of this information is subject to all applicable privacy legislation* Claim Number Policy Number Date of Accident YYYYMMDD Part 1 Applicant Information Last Name First Name and Initial Birth Date Province year month day Postal Code Work Telephone Home Telephone Extension Name of Insurance Company Representative Address City FAX Number Telephone Number Name of Health Professional Health Profession Part 4 Signature Part 3 Treating Health Professional Part 2 Insurance Company Date of Accident I authorize my treating health professional to collect use and disclose to my insurer or to a health professional social worker or vocational rehabilitation expert properly appointed by my insurer to conduct an examination 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. .

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