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Wisconsin Medical Records Release Form 1

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

Wisconsin Medical Records Release Form 1
Wisconsin Medical Records Release Form 1
HIM (Medical Records)
333 East Campus Mall, Rm 8102
Madison, WI 53715-1381
Phone: (608) 262-1676 Fax: (608) 262-9160
1. Regarding Patient COMPLETE IN FULL (See reverse side for further information)
Name - Last, First, MI
Street Address Telephone #
City State Zip Code
2. Records Released From
3. Records Released To
Name - (i.e. Health Facility, Physician...)
Name - (i.e. Insurance Co., Lawyer, Physician, Self...)
Street Address
Street Address
City State Zip Code
City State Zip Code
Phone #
Fax #
Phone #
Fax #
Records are needed for an appt on ____________/ Records needed to schedule appt. P/U Copies--call me when ready
4. INFORMATION TO BE RELEASED: (Check all applicable categories)
Complete Copy of Clinical Records Mental Health Summary Letter Psychiatry Transfer of Care
Womens Clinic Visits/Labs Only Complete Copy of MH Records Routine Complete copy of Mental
Allergy/Immunization Records Telephone/Verbal Communication and/or Medical Health Records
X-ray Report/Images Other_______________________ Psychiatry Split Care Letter
Lab Results ADHD
Occupational Health Record Complete copy of Medical Records
Complete copy of Psychoeducational
ADHD evaluation
In compliance with Wisconsin Statutes which require special permission to release otherwise privileged information,
please release records pertaining to: (Check applicable conditions)
Mental Health Alcohol Treatment/Evaluation HIV Test Results
Developmental Disabilities Drug Treatment/Evaluation Aids/Aids-Related Illness
5. PURPOSE OR NEED FOR DISCLOSURE: (Check applicable categories)
Further Health Care Insurance/Work Comp Occupational Health
Legal Personal/Self School Disability
Academics Other:
6. This authorization will remain in effect until this request is processed unless you specify this authorization will be effective for an
additional time period. Written consent is necessary to revoke this request.
Additional time period. Specify: NONE
Include future records generated during the additional time period
7. I authorize release of my health records in accordance with the specification listed above. I understand that I have a right to inspect
and receive a copy of the disclosed material. A photocopy of this consent shall be valid as the original.
8. Signature of patient Date
(If signed by person other than patient, state relationship and authority to do so.)
Release Date: _______________ #Pgs ________ Certified: Y N Via: Mail Fax Pick up Completed by Initials __________
Wisconsin Medical Records Release Form 1