December 10, 2018


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ONLINE AUTHORIZATION FORM

Please note that fields in RED are required. This form is only applicable in Ohio.


TO: The Ohio Bureau of Workers' Compensation Risk Technical Services Department (L-22)

Minute Men HR Risk Services
3740 Carnegie Avenue
Cleveland, OH 44115
Fax: 216-426-2254
Toll Free: 877-873-8856
TEMPORARY AUTHORIZATION
TO REVIEW INFORMATION
From (Policy Number):
Entity:
DBA:
Address:
City:
State:
Zip:
This is to certify that Minute Men HR Risk Services REP #001633-80 including its agents or representatives identified to you by them, has been retained to review and perform studies on certain workers' compensation matters on your behalf.

The limited letter of authority provides access to the following types of information relating to your account:
(1) Risk files
(2) Claim Files
(3) Merit-rated or non-merit rated experiences
(4) Other associated data

This authorization does NOT include the authority to:
(1) Review protest letters
(2) File protest letters
(3) File form CHP-4
(4) File Motions, I-12's or IC-88's
(5) File self-insurance applications
(6) Represent the employer at hearings
(7) Pursue other similar actions on behalf of the employer

I understand that this authorization is limited and temporary in nature and will expire on                                                    or automatically nine months from date received by the Risk Technical Department or Self-Insured Section, whichever is appropriate. In either case length of authorization will not exceed nine months.
Signature: Title: Date:
(typing name below
constitutes electronic signature)
Print Name: Telephone: Fax:


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Managed Care Organization (MCO)?
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