# Ohio Rev. Code § 3904.06: Disclosure authorization form

> Ohio · Statutes · In force

URL: https://www.frixlaw.com/law-library/statutes/STATE_OH_T39_C3904_S3904.06

## Section

- **Citation:** Ohio Rev. Code § 3904.06
- **Heading:** Disclosure authorization form
- **Jurisdiction:** Ohio
- **Kind:** Statutes
- **Status:** In force
- **Text as of:** August 14, 2026
- **Source:** Compiled text
- **Location:** Ohio Revised Code / Title 39 / Chapter 3904 / § 3904.06

## Text

June 29, 1995 House Bill 329 - 120th General Assembly No insurance institution, agent, or insurance support organization shall use as its disclosure authorization form in connection with insurance transactions a form or statement that authorizes the disclosure of personal or privileged information about an individual to the insurance institution, agent, or insurance support organization, unless the form or statement: (A) Is written in plain language; (B) Is dated; (C) Specifies the types of persons authorized to disclose information about the individual; (D) Specifies the nature of the information authorized to be disclosed; (E) Names the insurance institution or agent and identifies by generic reference representatives of the insurance institution to whom the individual is authorizing information to be disclosed; (F) Specifies the purposes for which the information is collected; (G) Specifies the length of time such authorization shall remain valid, which shall be no longer than: (1) In the case of authorizations signed for the purpose of collecting information in connection with an application for an insurance policy, a policy reinstatement, or a request for change in policy benefits, thirty months from the date the authorization is signed; (2) In the case of authorizations signed for the purpose of collecting information in connection with a claim for benefits under an insurance policy: (a) The term of coverage of the policy if the claim is for a health insurance benefit; (b) The duration of the claim if the claim is not for a health insurance benefit. (H) Advises the individual or a person authorized to act on behalf of the individual that the individual or the individual's authorized representative is entitled to receive a copy of the authorization form.

## Nearby sections

- [Ohio Rev. Code § 3904.01 § 3904.01. Insurance information practices definitions](https://www.frixlaw.com/law-library/statutes/STATE_OH_T39_C3904_S3904.01.md)
- [Ohio Rev. Code § 3904.02 § 3904.02. Applicability of chapter](https://www.frixlaw.com/law-library/statutes/STATE_OH_T39_C3904_S3904.02.md)
- [Ohio Rev. Code § 3904.03 § 3904.03. Pretext interviews](https://www.frixlaw.com/law-library/statutes/STATE_OH_T39_C3904_S3904.03.md)
- [Ohio Rev. Code § 3904.04 § 3904.04. Institution or agent to provide notice of information practices to applicants and policyholders](https://www.frixlaw.com/law-library/statutes/STATE_OH_T39_C3904_S3904.04.md)
- [Ohio Rev. Code § 3904.05 § 3904.05. Marketing or research questions](https://www.frixlaw.com/law-library/statutes/STATE_OH_T39_C3904_S3904.05.md)
- [Ohio Rev. Code § 3904.06 § 3904.06. Disclosure authorization form](https://www.frixlaw.com/law-library/statutes/STATE_OH_T39_C3904_S3904.06.md)
- [Ohio Rev. Code § 3904.07 § 3904.07. Investigative consumer report](https://www.frixlaw.com/law-library/statutes/STATE_OH_T39_C3904_S3904.07.md)
- [Ohio Rev. Code § 3904.08 § 3904.08. Written request for access to recorded personal information](https://www.frixlaw.com/law-library/statutes/STATE_OH_T39_C3904_S3904.08.md)
- [Ohio Rev. Code § 3904.09 § 3904.09. Correction, amendment or deletion of information](https://www.frixlaw.com/law-library/statutes/STATE_OH_T39_C3904_S3904.09.md)
- [Ohio Rev. Code § 3904.10 § 3904.10. Written reason for adverse underwriting decision summary of rights](https://www.frixlaw.com/law-library/statutes/STATE_OH_T39_C3904_S3904.10.md)
- [Ohio Rev. Code § 3904.11 § 3904.11. Inquiry concerning previous adverse underwriting decision](https://www.frixlaw.com/law-library/statutes/STATE_OH_T39_C3904_S3904.11.md)
- [Ohio Rev. Code § 3904.12 § 3904.12. Prohibited bases for adverse underwriting decision](https://www.frixlaw.com/law-library/statutes/STATE_OH_T39_C3904_S3904.12.md)
- [Ohio Rev. Code § 3904.13 § 3904.13. Disclosure of personal or privileged information](https://www.frixlaw.com/law-library/statutes/STATE_OH_T39_C3904_S3904.13.md)
- [Ohio Rev. Code § 3904.14 § 3904.14. Obtaining information under false pretenses](https://www.frixlaw.com/law-library/statutes/STATE_OH_T39_C3904_S3904.14.md)

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Source: Frix Law Library, https://www.frixlaw.com/law-library/statutes/STATE_OH_T39_C3904_S3904.06. Check the current official text before relying on it. Not legal advice.