Fill and Sign the Voluntary and Informed Consent for Workers Compensation Wisconsin

                                         A. B.       Person Authorized to sign for Patient:             A minor Incompetent Disabled Deceased Other:       Voluntary and Informed Consent for Disclosure of Health Care Information Department of Workforce DevelopmentWorker's Compensation Division201 E. Washington Ave., Rm C100P.O. Box 7901 Personal information you provide may be used for secondary purposes [Privacy Law, s. 15.04(1)(m)]. Madison W I 53707-7901 Telephone: (608) 266-1340 Fax: (608) 267-0394 http://www.dwd.state.wi.us/wc/ By law, all health care providers shall provide to any employee, employer, worker's compensation insurer or their 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 document 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 Care Provider's Name Health Care Provider's Address Patient's (Employee's Name) Employer's Name Patient's Social Security Number Patient's Birth Date The above-named patient authorizes the above-named health care provider to disclose all records checked below in its possessionrelating to the patient's health, treatment and evaluation to: or its designated representatives, and to deliver to them for inspection and/or copying all records, writings, reports, test results and x-rays in its possession containing such information. This release is for use in the preparation, evaluation and hearing of the worker's compensation matter listed above which is currently pending before the Worker's Compensation Division of the Department of Workforce Development. CHECK ONE: Physical Only. Release all records and information regarding the patient's physical health, treatment and evaluation including, but not 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, regulation, rule or other authority, including but not limited to ss. 146.81 and 146.82, Wis. Stats. Physical and Other . Release all records and information regarding the 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, physical 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 to ss. 51.30, 146.025, 146.81 and 146.82, Wis. Stats., and 42 C.F.R., Chap. 1, subpart C, sec. 2.31. 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 one (1) year from date signed, or upon termination of the above matter, whichever is later. A photostatic copy shall be as valid as the original. Patient's Signature: Date: Date: Authority/Des ig nation to sign is based on the fact that the patient is: NOTE: The party requesting disclosure shall provide to the patient-employee, upon request, a copy of all records received, at no charge to the patient employee. This information is being released from confidential records which are protected by law from re-release by you except as authorized in this document. WKC-9488 (R. 03/2001)