Department of Workforce Development Bureau of Insurance

Department of Workforce Development

Worker’s Compensation Division

201 E. Washington Ave., Rm. C100

P.O. Box 7901

Madison, WI 53707

Telephone: (608) 266-1340

Fax: (608) 267-0394

http://dwd.wisconsin.gov/wc/

e-mail: DWDDWC@dwd.wisconsin.gov

The patient named above hereby authorizes the health care provider named above to disclose all records checked below in its possession relating to the patient's health, treatment and evaluation to:

or its designated representatives, and to furnish to them a legible, certified duplicate of all records, writings, reports, test results and x-rays in its possession containing such information. This authorization includes all records, reports, correspondence, or other materials in the possession of the health care provider authorized, even if those materials were not generated by the health care provider, and the redisclosure of such materials is hereby authorized. This release is for use in the investigation, preparation, evaluation, and/or hearing of the worker's compensation claim described above.

CHECK ONE:

In signing this consent form, I acknowledge that I understand that:

• I am authorizing release of the records and information listed above.

• I am waiving any privilege that may otherwise prevent disclosure of the records and information listed above.

• I understand that the health care provider named above, whom I am authorizing to disclose my protected health information, may not condition my treatment, payment, enrollment or eligibility for benefits (if applicable) on whether I sign this authorization, except: (1) if my treatment is related to research, or (2) health care services are provided to me solely for the purpose of creating protected health information for disclosure to a third party.

• I may revoke this authorization at any time by written request to the party authorized above to receive information. However, I understand that my revocation is not effective with respect to actions a covered entity took in reliance on this authorization or as needed for an insurer to contest a claim/policy authorized by law if signing the authorization was a condition to obtaining insurance coverage.

• I may obtain a copy of the disclosed records and information, upon written request to the party authorized above to receive information, at no charge to me.

• My personal health information disclosed pursuant to this authorization may be redisclosed and may no longer be protected by federal law. My personal health information may be released to any of the following: the employer, the worker’s compensation insurer, the Department of Workforce Development, other parties to this matter or their attorneys; the Labor and Industry Review Commission; any court on any action or proceeding relating to this matter; experts retained or consulted by any party; and any of their agents, employees, or representatives. I specifically authorize and consent to any such disclosure and redisclosure.

• I am entitled to a copy of this consent form after I sign it.

If you have any questions about this document, you should contact the Worker's Compensation Division at (608) 266-1340. You should not sign this document if the name of the health care provider is blank.

This consent is subject to revocation at any time. If not revoked, this consent is effective for two (2) years from date signed. This authorization expressly waives any requirement that it must be used within a certain number of days after the date of signing, or that it must be dated within any time period before the date it is used. This authorization shall also extend to records of future treatment, after the date of signing of this authorization, as long as such treatment occurs while this authorization is still in effect. A photocopy copy shall be as valid as the original.