Fill and Sign the Department of Workforce Development Bureau of Insurance Form

Page 1 of 2 Voluntary and Informed Consent for Disclosure of Health Care Information *Provision of your Social Security Number (SSN) is voluntary . Failure to provide it may result in an information processing delay . Personal information you provide may be used for sec ondary purposes [Privacy Law, s. 15.04 (1)(m), Wisconsin Statutes]. Department of Workforce Development Worker’s Compensation Division 201 E. W ashington Ave., Rm. C100 P.O. Box 7901 Madison, W I 53707 Telephone: (608) 266 -1340 Fax: (608) 267 -0394 http://dwd.wisconsin.gov /wc/ e-mail: DW DDW C@dwd.wisconsin.gov By law, all health care providers must provide to any employee, employer, worker's compensation insurer or thei r representative any information reasonably related to any alleged work injury. However, determining the relationship of prior medical records to a work injury can be difficult and time -consuming. Therefore, to assist in the timely investigation of your claim, this document authorizes the health care provider to release medical information without attempting to determine the extent of its relationship to your alleged work injury. You are not required to sign this document. You may refuse to sign this docume nt without jeopardizing your right to collect worker's compensation benefits. However, by assisting in the investigation of your claim, you are likely to receive benefits quicker than if you refuse to authorize the release of medical information. Health Ca re Provider Name Street Address P.O. Box City State Zip Code Patient (Employee) Name Employer Name Patient Social Security Number * - - Patient Birth Date WC Claim No. The patient named above hereby authorizes the health care provider named above to disclo se all records checked below in its possession relating to the patient's health, treatment and evaluation to: Name and Address of Party Authorized to Receive Protected Information or its designated representatives, and to furnish to th em 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 wor ker's compensation claim described above. CHECK ONE: A. Physical Only . Release all records, correspondence, and any other information from whatever source regarding the patient's physical health, treatment and evaluation including, but no t limited to, any made or provided by any physician, nurse, chiropractor, osteopath, dentist, physical therapist, hospital, or any other health care provider. This consent constitutes a waiver of any privilege created by state or federal statute, regula tion, rule or other authority, including but not limited to W is. Stat. §§ 146.81 and 146.82, and 45 C.F.R. § 164.508. B. Physical and Other . Release all records, correspondence, and any other information from whatever source regarding th e patient's physical and mental health, drug and alcohol abuse, HIV and AIDS tests, treatment, and evaluation including, but not limited to, any made or provided by any physician, psychiatrist, psychologist, nurse, chiropractor, osteopath, dentist, physica l therapist, hospital or any other health care provider. This consent constitutes a waiver of any privilege created by state or federal statute, regulation, rule or other authority, including but not limited W is. Stat. §§ 51.30, 146.025, 146.81 and 146. 82, 42 C.F.R., Chap. 1, subpart C, § 2.31 and 45 C.F.R. § 164.508. Patient Signature (or Person Authorized to Sign for Patient) — for Option B Patient Signature (or Person Authorized to Sign for Patient) Date Signed WKC -9488 (R. 06/20 17) Page 2 of 2 In si gning 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 thi s authorization at any time by written request to the pa rty authoriz ed 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 in formation 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 W orkforce 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 W orker's Compensation Di vision 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 authorizat ion expressly waives any requirement that it must be used within a certain number of days after the date of sign ing, 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 whil e this authorization is still in effect. A photocopy copy shall be as valid as the original. Patient Signature (or Person Authorized to Sign for Patient) Date Signed If not signed by patient, authority/designation to sign is based on the fact that the patient is A minor Incompetent Disabled Deceased Other: