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.
AUTHORIZATION TO RELEASE PROTECTED HEALTH INFORMATION
(Complete in full. See reverse side for important information.)
Name of Patient
City, State, Zip code
Date of Birth
I authorize the use and/or release of my protected health
information as described below. I understand that the information
used or released as a result of this Authorization may no longer be
protected by federal privacy laws and may be further used or
released by persons or organizations receiving it without
obtaining my authorization. I may refuse to sign this
Authorization, which will not affect my ability to obtain treatment
or payment of claims. I have the right to revoke this
Authorization by providing written notice to Dean Health System,
Health Information Services Department. Revocation of this
Authorization will not affect any action taken before receipt of
the written revocation.
2. AUTHORIZE:3. TO RELEASE PROTECTED HEALTH INFORMATION TO:
(If Release is to Self, State Self)
(Name of Physician/Health Care Facility/Other) (Name of Physician/Health Care Facility/Other)
(Street Address) (Street Address)
(City, State, Zip Code) (City, State, Zip Code)
4. HEALTH INFORMATION TO BE RELEASED:
All Medical Records Immunization Records Lab Reports X-ray Reports X-ray films (specify) Billing Records (specify)
FOR THE FOLLOWING DATE(S) OR TIME FRAME: From: / / (DD/MM/YYYY) To: / /
4a. Federal and state laws require special permission to release certain information. Please check if these records should be released:
Mental Health Alcohol and/or drug abuse HIV/AIDS test results Developmental Disabilities
5. PURPOSE OR NEED FOR DISCLOSURE: (Check applicable categories)
Further Medical Care Patient’s Request Insurance Eligibility/Benefits Disability Determination Legal Investigation
This authorization will expire on
/ / (DD/MM/YYYY). If I do not indicate a date, this will expire one (1) year
from the date of my signature below. A photocopy of this authorization is as valid as the original.
I understand that this authorization is voluntary. I am confirming my authorization that the health care provider may use and/or disclose to the
persons and/or organizations named in this form the protected health information described in this form.
If this Authorization is signed by a representative on behalf of the patient, complete the following:
Relationship to Patient:
YOU ARE ENTITLED TO A COPY OF THIS AUTHORIZATION AFTER YOU SIGN IT.
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