Permission to Disclose Health Information (OCF-5) – SABS

The Permission to Disclose Health Information (OCF-5) form is used to authorize the collection, use, and disclosure of health information related to automobile accidents occurring on or after January 1, 1994. The OCF-5 form ensures that the handling of health information complies with all applicable privacy legislation.

This document is critical in managing the legal and medical processes following an automobile accident, ensuring that necessary health information is available for effective treatment and benefit determination while maintaining compliance with privacy laws.

The OCF-5 form is essential for managing health information related to automobile accidents. Here is a step-by-step guide to completing the form correctly:

1. Return Information

• Return this form to: The address where the completed form should be sent. This will typically be provided by your insurer or the entity requesting the information.

2. Applicant Information

• Last Name, First Name, and Initial: Enter your legal last name, first name, and middle initial.
• Date of Accident (YYYYMMDD): Enter the date of the automobile accident in the format year-month-day.
• Address: Provide your complete residential address, including street, city, province, and postal code.
• Birth Date (YYYYMMDD): Enter your birth date in the format year-month-day.
• Home Telephone: Enter your home phone number.
• Work Telephone and Extension: Enter your work phone number and extension, if applicable.

3. Insurance Company Information

• Name of Insurance Company: Enter the full name of your insurance company.
• Name of Insurance Company Representative: Enter the name of your insurance representative handling your claim.
• Address: Provide the insurance company’s address, including street, city, province, and postal code.
• Telephone Number: Enter the phone number for the insurance company.
• FAX Number: Enter the fax number for the insurance company, if available.

4. Treating Health Professional Information

• Name of Health Professional: Enter the name of the health professional treating you.
• Health Profession: Specify the health professional’s occupation (e.g., physician, chiropractor).
• Address: Provide the health professional’s address, including street, city, province, and postal code.
• Telephone Number: Enter the phone number for the health professional’s office.
• FAX Number: Enter the fax number for the health professional’s office, if available.

5. Authorization for Disclosure

• Part 4: Read this section carefully. By signing, you authorize your treating health professional to collect, use, and disclose health information to your insurer or other designated professionals as needed for treatment and determining eligibility for benefits.
  • This authorization is valid until your claim for Statutory Accident Benefits is concluded or until you withdraw your consent. Withdrawal of consent may impact your benefit entitlement.
  • Separate consent is required for consultations between your healthcare provider and the insurer’s health professional.

6. Signatures

• Name of Applicant or Substitute Decision Maker (please print): Print your name or the name of your substitute decision-maker if you are unable to sign.
• Signature of Applicant or Substitute Decision Maker: Provide your signature or the signature of your substitute decision maker.
• Date (YYYYMMDD): Enter the date when the form is signed in the format year-month-day.

Additional Notes

• Ensure all sections are completed accurately and legibly.
• Keep a copy of the completed form for your records.
• If you have any questions while filling out the form, contact your insurance representative for assistance.

By following these instructions, you can ensure that your Permission to Disclose Health Information (OCF-5) form is completed correctly, facilitating the smooth processing of your claim and the necessary medical treatment.