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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
Wisconsin Medical Records Release Form 2
Medical Records Release Policy and Procedure
In response to the Health Insurance Portability and Accountability Act (HIPPA) of 1996, physicians have been faced
with greater complexities when releasing medical records. In an effort to protect patient confidentiality, as well as
comply with government regulations, Wisconsin Fertility Institute has developed policies and procedures to insure
that your confidential medical records are handled in a manner meeting all necessary guidelines.
Medical Records will be released only upon written request from the patient. Written requests must be in
accordance with the Uniform Health Care Information Act.
Wisconsin Fertility Institute will only release records that were created and maintained by our doctors and clinic.
We will not release records received from other clinics or providers.
The requirements for a valid authorization to release medical records are:
In writing, dated and signed by patient
Specifically identifies patient
Specifically identifies the healthcare provider who is to make the disclosure
Specifically identifies the information to be disclosed
Note: an authorization which affects a medical record in which information concerning the performance or results of
HIV (AIDS virus), STD testing, substance abuse, and mental or psychiatric treatment must specifically authorize the
release of such test and/or treatment information or it will be excluded from the records release.
Specifies the name, address and institutional affiliation of the person or entity to whom the information is to
be disclosed
Except for authorizations to provide information to third-party payers, authorizations are valid for 2 years. Patients
can specify a shorter period of time if desired.
Revocation must be in writing; an authorization can be revoked at any time unless:
Needed to secure payment for services rendered; or
Other substantial actions have been taken in reliance on the authorization
(e.g. a claim has been made under a life insurance or disability policy)
Wisconsin Medical Records Release Form 2