form disability auth osu

Transcript

1 Printed Name: ___________________________________________________ Soc. Sec. # _____________________________________ r, TO: Any physician or health care provide y, medical clinic, or pharmacy , Any hospital, mental health facilit y, Any vocational rehabilitation agenc The Ohio Public Employees Retirement System (“OPERS”), The State Teachers Retirement System of Ohio (“STRS”), The subsidiaries of Unum Group (“Unum”), orkers’ Compensation, The Ohio Bureau of W The Industrial Commission of Ohio. I hereby authorize you to release to The Ohio State University (“OSU”) any and all records and information described in (1) through (4) below: (1) Records and information about my health, including information concerning my physical and mental condition and medical histor y, including but not limited to diagnoses, prognoses, treatment, recommendations for treatment, opin- y ions of disabilit , objective findings and test results, and periods of hospitalization; (2) Records and information concerning my education, training and experience; (3) Records and information concerning my employment, including but not limited to dates of employment, compensation, my job description and any employee or union benefits which I am receiving or to which I may be entitled, and (4) Records or information concerning any benefits which I am receiving or to which I may be entitled, including but not limited to the applications for such benefits. AIDS; Information about my health may relate to any disorder of the immune system including, but not limited to, HIV and use of drugs and alcohol; and mental and physical histor y, condition, advice or treatment, but does not include psycho - therapy notes. I understand that OSU will use any information it obtains pursuant to this authorization to assist me in my return to work and/or vocational e f forts and/or to otherwise assist me in pursuing my claim(s) for benefits. I further understand that information released pursuant to this authorization may no longer be protected under the HI PAA Privacy Rule, but may continue to be protected under other state or federal laws or regulations. I further hereby authorize OSU to release to any vocational rehabilitation agenc The Ohio Bu - y, OPERS, STRS, Unum, orkers’ Compensation, and The Industrial Commission of Ohio any and all records and information described in reau of W than as provided in this authorization, OSU will not further disclose any information it receives (1) through (4) above. Other w. without further authorization from me or unless otherwise permitted by la I understand and agree that this authorization shall remain valid as long as one of the following is applicable and in e ffect: [a] I am participating in the a return to work or vocational rehabilitation program with Unum; [b] I have a disability claim with Unum that is pending or active; [ci I have an OPERS disability claim that is pending or active; [d] I have a STRS dis - ability claim that is pending or active; [e] I have a W orkers’ Compensation claim that is pending or active; or [1] my em - ployment at OSU is in some type of active, leave-of-absence, or disability separation status, or 1 yea r, which ever is less. A photocopy of this document shall be as valid as the original. I understand that I am entitled to receive a copy of this authorization. I may revoke this authorization in writing at any time except to the extent OSU has relied on the authorization prior to no - tice of revocation. I may revoke this authorization by sending written notice to the following address: Unum, The Benefits Cente r , P .O. Box 100158, Columbia, SC 29202-3158. ____________________________________________________________ __________________________ Signature Date If signing on behalf of the individual under a Power of Attorney or Guardian or Conservator relationship, please attach a copy of the document granting authorit y. Doc 372835

Related documents

DER Directory

DER Directory

FAA CONSULTANT DER DIRECTORY May 9, 2019 AIR-6F0, Delegation & Organizational Procedures Branch This directory is generated from information in the FAA Designee Information Network (DIN). If you are a...

More info »
Microsoft Word   A) Division 245.docx

Microsoft Word A) Division 245.docx

tables Attachment Division 245, including A: Nov. 15-16, 2018, EQC meeting 1 of 121 Page Division 245 CLEANER AIR OREGON 340-245-0005 Purpose and Overview (1) This statement of purpose and overview is...

More info »
Baldwin Copyright Wars CC.pdf

Baldwin Copyright Wars CC.pdf

The Copyright Wars T THE COPYRIGHT WARS: THREE CENTURIES OF TRANS-ATLANTIC BATTLE by Peter Baldwin is licensed under a Creative Commons Attribution-NonCommercial-NoDerivatives 4.0 International Licens...

More info »
Gutmans Frontmatter

Gutmans Frontmatter

Gutmans_Frontmatter Page i Thursday, September 23, 2004 9:05 AM PHP 5 Power Programming

More info »
ayout 1

ayout 1

0465039146-FM:FM 12/5/06 12:25 AM Page i C O D E

More info »
AWS Certificate Manager Private Certificate Authority   User Guide

AWS Certificate Manager Private Certificate Authority User Guide

AWS Certificate Manager Private Certificate Authority User Guide Version latest

More info »
Board of Property Tax Appeals Manual, 150 303 484

Board of Property Tax Appeals Manual, 150 303 484

Board of Property Tax Appeals Manual Oregon Department of Revenue 150-303-484 (Rev. 08-17)

More info »
Ubuntu Server Guide

Ubuntu Server Guide

Ubuntu Server Guide

More info »
Hawaii Administrative Rules Chapter 16   97 Private Detectives and Guards

Hawaii Administrative Rules Chapter 16 97 Private Detectives and Guards

HAWAII ADMINISTRATIVE RULES TITLE 16 DEPARTMENT OF COMMERCE AND CONSUMER AFFAIRS CHAPTER 97 PRIVATE DETECTIVES AND GUARDS Subchapter 1 General Provisions §16-97-1 Objective §16-97-2 Definitions §16-97...

More info »
TPM Main Part 3 Commands v1.2 rev116 01032011

TPM Main Part 3 Commands v1.2 rev116 01032011

1 2 1 2 3 4 5 6 7 8 TPM Main Part 3 Commands 9 10 Specification Version 1.2 11 Level 2 Revision 116 12 1 March 2011 13 TCG Published 14 15 16 17 Contact: [email protected] 18 19 20 21 22...

More info »
Linux Client Migration Cookbook Version 2

Linux Client Migration Cookbook Version 2

Front cover Linux Client Migration Cookbook, Version 2 A Practical Planning and Implementation Guide for Migrating to Desktop Linux For any organization that is exploring or planning for a Linux deskt...

More info »
Qualys(R) Asset Management and Tagging v2 API User Guide

Qualys(R) Asset Management and Tagging v2 API User Guide

Asset Management & Tagging API User Guide Version 2.37 March 29 , 2019

More info »
Hawaii Administrative Rules Chapter 90 C Nursing Home Administrators

Hawaii Administrative Rules Chapter 90 C Nursing Home Administrators

HAWAII ADMINISTRATIVE RULES { } PRIVATE 16 TITLE DEPARTMENT OF COMMERCE AND CONSUMER AFFAIRS 90 CHAPTER NURSING HOME ADMINISTRATORS Subchapter 1 General Provisions §16-90-1 Objective §16-90-2 Definiti...

More info »
Division 2, Subdivision D, Walking Working Surfaces *

Division 2, Subdivision D, Walking Working Surfaces *

Oregon Administrative Rules Chapter 437 Division 2 ccupational Safety and Health General O Subdivision Working Surfaces Walking - AO 2 - 201 7

More info »
Bugs for Cisco IOS Release 15.5(3)M

Bugs for Cisco IOS Release 15.5(3)M

Bugs for Cisco 15.5(3)M IOS Release and Resolved Bugs, on page 1 • Open Tool, on page 2 the Bug Search • Using 15.5(3)M9 , on page 3 Bugs—Cisco IOS Release • Resolved • Resolved IOS Release 15.5(3)M8 ...

More info »
Qualys Web Application Scanning API User Guide

Qualys Web Application Scanning API User Guide

Web Application Scanning API User Guide Version 2.38 April 09, 2019

More info »
CityNT2019TentRoll 1

CityNT2019TentRoll 1

STATE OF NEW YORK 2 0 1 9 T E N T A T I V E A S S E S S M E N T R O L L PAGE 1 VALUATION DATE-JUL 01, 2018 COUNTY - Niagara T A X A B L E SECTION OF THE ROLL - 1 CITY - North Tonawanda TAX MAP NUMBER ...

More info »
Microsoft Word   JUSTICE #3954535 v6 OAR 137 050 0700 commentary

Microsoft Word JUSTICE #3954535 v6 OAR 137 050 0700 commentary

Child Support Guideline Rules Rule Number 137-050-0700 General Provisions Calculating Support 137-050-0710 137-050-0715 Income Adjusted Income 137-050-0720 Basic Support Obligation 137-050-0725 Parent...

More info »