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Wisconsin Medical Records Release Form 2

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This form is provided by Wisconsin Fertility Institute to authorize the disclosure or release of one person's protected health information.

Wisconsin Medical Records Release Form 2 Page 2
Wisconsin Medical Records Release Form 2
GUIDELINES FOR COMPLETION OF AUTHORIZATION TO RELEASE MEDICAL INFORMATION FROM
WISCONSIN FERTILITY INSTITUTE
1. This form can be used to release medical records from WFI.
2. Complete the patient’s name, daytime phone #, and date of birth.
3. Complete the name and address of the person/facility that the records are to be released to.
4. Check the reason for releasing this information (Purpose of this Disclosure).
5. Identify the appropriate dates of service for the records that are to be released.
**Please initial if you would like your future records to be released as part of this completed authorization.**
6. Check the appropriate information that is to be released (copied and/or faxed).
7. Review your rights for this authorization.
8. Review the expiration date of the authorization. If you would like a different expiration date, please indicate.
9. Obtain the patient or legal representative’s signature (relationship) and date.
10. If this request relates to AIDS/HIV, Mental Health Care, Alcohol/Drug Use, or Development Disabilities, please
sign and date under the specified section.
Wisconsin Medical Records Release Form 2