Ohio § 5101.272 Authorization form

Ohio Statutes

§ 5101.272 — Authorization form

Ohio § 5101.272

Title 51Public Welfare

Ch. 5101Department of Job and Family Services- General Provisions

This text of Ohio § 5101.272 (Authorization form) is published on Counsel Stack Legal Research, covering Ohio primary law. Counsel Stack provides free access to over 12 million legal documents including statutes, case law, regulations, and constitutions.

Bluebook

Ohio Rev. Code Ann. § 5101.272 (2026).

Text

(A)For the purposes of section5101.27of the Revised Code, an authorization shall be made on a form that uses language understandable to the average person and contains all of the following:

(1)A description of the information to be used or disclosed that identifies the information in a specific and meaningful fashion;

(2)The name or other specific identification of the person or class of persons authorized to make the requested use or disclosure;

(3)The name or other specific identification of the person or governmental entity to which the information may be released;

(4)A description of each purpose of the requested use or disclosure of the information;

(5)The date on which the authorization expires or an event related either to the individual who is the subject of the request

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(A) For the purposes of section5101.27of the Revised Code, an authorization shall be made on a form that uses language understandable to the average person and contains all of the following:

(1) A description of the information to be used or disclosed that identifies the information in a specific and meaningful fashion;

(2) The name or other specific identification of the person or class of persons authorized to make the requested use or disclosure;

(3) The name or other specific identification of the person or governmental entity to which the information may be released;

(4) A description of each purpose of the requested use or disclosure of the information;

(5) The date on which the authorization expires or an event related either to the individual who is the subject of the request or to the purposes of the requested use or disclosure, the occurrence of which will cause the authorization to expire;

(6) A statement that the information used or disclosed pursuant to the authorization may be disclosed by the recipient of the information and may no longer be protected from disclosure;

(7) The signature of the individual or the individual's authorized representative and the date on which the authorization was signed;

(8) If signed by an authorized representative, a description of the representative's authority to act for the individual;

(9) A statement of the individual or authorized representative's right to prospectively revoke the written authorization in writing, along with one of the following:

(a) A description of how the individual or authorized representative may revoke the authorization;

(b) If the department of job and family services' or department of children and youth's privacy notice contains a description of how the individual or authorized representative may revoke the authorization, a reference to that privacy notice.

(10) A statement that treatment, payment, enrollment, or eligibility for public assistance cannot be conditioned on signing the authorization unless the authorization is necessary for determining eligibility for the public assistance program.

(B) When an individual requests information pursuant to section5101.27of the Revised Code regarding the individual's receipt of public assistance and does not wish to provide a statement of purpose, the statement "at request of the individual" is a sufficient description for purposes of division (A)(4) of this section.

Last updated August 6, 2025 at 3:36 PM