FORM 29.0 - APPLICATION TO RELEASE MEDICAL RECORDS AND MEDICAL BILLING RECORDS
Effective Date: May 1, 2021
PROBATE COURT OF ______________________ COUNTY, OHIO
_____________, JUDGE
ESTATE OF ____________________________________________________, DECEASED
CASE NO. __________
APPLICATION TO RELEASE MEDICAL RECORDS AND MEDICAL
BILLING RECORDS
[R.C. 2113.032]
Now comes ________________________________________ the _______________________ of the
(Applicant’s Name) (Relationship)
above named decedent who died on and resided at __________________
whose last four (4) digits of his/her social
security number are , and hereby requests authority to obtain information regarding
decedent’s medical records and medical billing records for the purpose of evaluating a potential
wrongful death, personal injury, or survivorship action on behalf of the decedent.
Applicant states the following:
☐ Applicant is an individual who is eligible to be appointed as a personal representative of the above-
named decedent’s estate under Ohio law; or
☐ Applicant is named as executor in the above-named decedent’s will, and Applicant has filed a copy
of decedent’s will with this Application.
Applicant has attached Form 1.0 – Surviving Spouse, Children, Next of Kin, Legatees and Devisees.
Applicant acknowledges that an order shall not be issued until ten days following the probate court’s
transmission of a copy of this application to those persons listed on the Form 1.0 who have not filed a
signed Waiver of Notice/Consent.
___________________________________________
Signature
___________________________________________
Typed or Printed Name
___________________________________________
Address
___________________________________________
___________________________________________
Phone Number
