Return this form to:
Permission to Disclose
Health Information (OCF-5)
Use this form for accidents that occur on or after January 1, 1994.
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 Date of
Accident
year month day
Address
City Province Postal Code
Birth
Date
year month day Home Telephone
Work Telephone Extension
Part 2
Insurance
Company
Information
Name of Insurance Company
Name of Insurance Company Representative
Address City
Province Postal Code Telephone Number
FAX Number
Part 3
Treatin
g
Health
Professional
Name of Health Professional Health Profession
Address
City Province Postal Code
Telephone Number
FAX Number
I authorize my treating health professional to collect, use and disclose to my insurer or to a health professional,
Part 4
social worker, or vocational rehabilitation expert properly appointed by my insurer to conduct an examination,
Signature
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
professional conducting an examination. Separate express consent is required for this consultation. This
consent should be in writing.
Name of Applicant or Substitute Decision Maker (please print) Signature of Applicant or Substitute Decision Maker
Date (YYYYMMDD)
Effective (2010-09-01) OCF–5
FSCO (1225E) Page 1 of 1
click to sign
signature
click to edit
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