Ontario Claim Form 5 (OCF-5)
Permission to Disclose Health Information

Effective September 1, 2010.

If your lawyer asks you to, please complete this form. The insurance company requires
your medical information in order to correctly determine your eligibility for benefits. Health
professionals require your written permission to disclose this information to the insurance company.

Upon signing this document, you’ll authorize your treating health professional to collect, use and disclose to your insurer or to a health professional, social worker, or vocational rehabilitation expert properly appointed by your insurer to conduct an examination. This is concerning only such information relating to your 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 your recovery as a result of your motor vehicle accident, as is reasonably required for the purpose of providing treatment and determining your eligibility for benefits.

This authorization is valid until your claim for Statutory Accident Benefits has been concluded or until you withdraw this consent.

This authorization does not apply to a consultation between your health care provider and the insurer’s health professional conducting an examination. Separate express consent is required for this consultation. This consent shall be in writing.

Please print clearly.

If you want to learn more about the companion accident benefits claim, and kickstarting the accident benefits application process, then please click the “link” to read my blog entitled “How to Get Your Accident Benefits Application Started”.