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Wisconsin Authorization To Release Protected Health Information

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This form is provided by Dean Health System to authorize the disclosure or release of one person's protected health information.

Wisconsin Authorization To Release Protected Health Information Page 2
Wisconsin Authorization To Release Protected Health Information
ADDITIONAL INFORMATION REGARDING RELEASE OF HEALTH INFORMATION
Dean Health System recognizes the patient’s right of confidentiality of their health information under federal privacy
regulations and Wisconsin law. The patient should be aware of the following information when requesting or releasing
health information.
à Right to Refuse to Sign This Authorization: A patient may refuse to sign this Authorization and this refusal will
not affect the patient’s ability to obtain treatment or payment of claims.
à Right to Inspect or Copy the Health Information to Be Used or Disclosed: A patient has the right to inspect or
copy the health information they have authorized to be used or disclosed by signing this Authorization form. A
patient may arrange to inspect their health information by contacting the office listed below.
à Right to Receive Copy of This Authorization: A patient has the right to receive a copy of the signed Authorization
form.
à Right to Revoke This Authorization: A patient has the right to revoke this Authorization at any time by giving
written notice of revocation to the Privacy Officer listed below. Revocation of this Authorization will not affect any
action taken in reliance of this authorization before receipt of the written notice of revocation.
à Multiple Releases of Information: A patient may request multiple releases of the information stated on the
Authorization form. However, all releases based on this form are limited to records dated up to and including the date
of the patient’s signature. A new Authorization is necessary for release of information for care provided after the date
of the patient’s signature, unless the Authorization specifically states that specific records that will be generated in the
future may be released, for example “future records of a specific test” or “ future records of specific clinic
appointment.”
à Who May Sign This Authorization:
1 Generally, all patients 18 years of age and older must sign for release of their own health information unless the
following conditions apply:
a. The patient is incompetent
b. The patient is disabled and cannot sign the form
c. The patient is deceased. (A surviving spouse or personal representative of the estate may sign. If there is
no surviving spouse or personal representative, then an adult member of the immediate family may sign.)
2 All persons signing for release of health information on behalf of the patient must state their relationship to the
patient and provide proof of legal authority of their capacity to act for the patient.
3 Minors: Patients less than 18 years of age must sign for release of their health information in the following cases:
a. Alcohol or other drug abuse treatment: age 12 or older
b. Mental health treatment: age 14 or older may consent to release of records without parental consent
(Parents also retain the right to access this information.)
c. HIV test results: age 14 or older
d. Emancipated minors who are married or in the military
à Fees for Records: Dean Health Systems may charge a reasonable fee for viewing, copying, postage and preparation
of records to fulfill this request. All fees are based on the applicable laws governing release of health information.
à Contact Office:
1. Requests for release of health information
can be directed to the Medical Records Department or other
appropriate department at the site where the services were provided or you may call our main office 608/252-
8275.
2. All questions regarding federal privacy regulations
can be directed to:
DHS Privacy Officer: 1808 West Beltline Highway, Madison, WI 53713
Telephone: 608 / 250-1075, E-Mail: [email protected]
Clinic Policy & Procedure No. 183-6035
Wisconsin Authorization To Release Protected Health Information
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