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

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.