Confidential information release authorization




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DEPARTMENT OF CHILDREN AND FAMILIES

Sections 19.35 & 19.36, Wis. Stats.




CONFIDENTIAL INFORMATION

RELEASE AUTHORIZATION

Completion of this form authorizes the release of information described in the section below called “Specific Description of Records Authorized for Release.” The person (record subject) whose records are released may have a right to inspect and, upon paying any applicable fees, obtain a copy of the disclosed records. Except for medication/somatic treatment records, a director/designee of a treatment facility for mental illness, developmental disability, alcohol or drug abuse may deny that right during treatment in some circumstances. Section 51.30, Wis. Stats., DCF 92.03-92.06 Wis. Adm. Code.




Name – Person Whose Records Will be Released (Record Subject)

     


Address

     


City, State, Zip Code

     


Identifying Number (If Any)

     


Date of Birth

     


Name & Address – Agency/Organization I Authorize to Release Information

     



Name - Information May be Released To

     


     

Organization

     


     

Address

     


     

City, State, Zip Code

     


Specific Description of Records Authorized for Release (Include dates of records, if applicable)

     


Purpose or Need for Release of Information (Be Specific)

     


Understandings


  • This authorization is voluntary. Refusal to sign will not affect treatment, payment, enrollment or benefits eligibility except for:

 No exceptions  Exceptions (specify):      

  • The information that I authorize to be released may be redisclosed by the recipient of the records only if allowed by law. If information is redisclosed, the recipient of the redisclosed information may be controlled by different laws.

  • I may revoke this authorization, in writing, at any time except for information already released as a result of this authorization. The written revocation must be given to the agency/organization I authorized to release information.

  • Unless revoked, this authorization will remain in effect until the expiration time indicated below.

Choose One:






Authorization expires as of       (Date).















Authorization expires    month(s) from the date I sign this authorization.















Authorization expires after the following action takes place:      




As evidenced by my signature, I hereby authorize disclosure of records to the person(s) or agency(s) specified above.

SIGNATURE - Person Whose Records Will be Released (Record Subject) Date Signed










SIGNATURE - Other Person Legally Authorized to Consent to Disclosure Title or Relationship to Record Subject Date Signed













DCF-F-369-E (N. 03/2011)


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