AUTHORIZATION FOR DISCLOSURE OF HEALTH INFORMATION
WVH–Chippewa Falls

2175 E. Park Ave.

Chippewa Falls, WI 54729

(715) 720-6775 Fax (715) 720-6672	WVH–King

N2665 County Rd. QQ

King, WI 54946-0600

Medical Records:

(715) 258-5586 Ext. 2238

Fax (715) 256-3204

Admissions:

(715) 258-5586

Fax (715) 256-3207	WVH–Union Grove

21425 G Spring St.

Union Grove, WI 53182

Medical Records:

(262) 878-6702 Ext. 5531

Fax (262) 878-6778

1.
Name of Member
Birth Date
2.	AUTHORIZES:
3.	RELEASE PROTECTED HEALTH INFORMATION TO:
Name of Health Care Provider
Name
Street Address
Street Address
City, State, Zip Code
City, State, Zip Code
4.	INFORMATION TO BE RELEASED:
Dates of Service
History and Physical
Discharge Summary
Medication Sheets
Laboratory Reports
Consultations
X-ray Reports
Other (specify):
In compliance with Wisconsin and Federal Statutes which require special permission to release otherwise privileged information, please release records pertaining to:
Mental Health
Developmental Disabilities
Alcoholism
Drug Abuse
HIV (AIDS)
Sexually Transmitted Diseases
Other (specify):
Sickle Cell Anemia
For the following date(s):
5.	PURPOSE FOR NEED OF DISCLOSURE: (check applicable categories)
Continuity of Care
Personal
Insurance Eligibility/Benefits
Legal Investigation or Action
Other (specify):
6.	This form authorizes release of information in accordance with Wis. Statutes 51.30, 252.15, and 146.81-146.84 and the Health Insurance Portability and Accountability Act, 45 CFR Parts 160 and 164, and 38 U.S.C. 5701 and 7332.

I understand that if the person(s) and/or organization(s) listed above are not health care providers, health plans or health care clearinghouses who must follow the federal privacy standards, the health information disclosed as a result of this authorization may no longer be protected by the federal privacy standards and my health information may be redisclosed without obtaining my authorization.

7.	Your Rights with Respect to This Authorization
Right to Inspect or Copy the Health Information to be Used or Disclosed — I understand that I have the right to inspect or copy the health information I have authorized to be used or disclosed by this authorization form. I may arrange to inspect my health information or obtain copies of my health information by contacting Medical Records.

Right to Receive Copy of This Authorization — I understand that if I agree to sign this authorization, which I am not required to do, I must be provided with a signed copy of the form.

Right to Refuse to Sign This Authorization — I understand that I am under no obligation to sign this form and that the person(s) and/or organization(s) listed above who I am authorizing to use and/or disclose my information may not condition treatment, payment, enrollment in a health plan or eligibility for health care benefits on my decision to sign this authorization.

Right to Withdraw This Authorization — I understand written notification is necessary to cancel this authorization. To obtain information on how to withdraw my authorization or to receive a copy of my withdrawal, I may contact Medical Records. I am aware that my withdrawal will not be effective as to uses and/or disclosures of my health information that the person(s) and/or organization(s) listed above have already made in reference to this authorization.
8.	Expiration Date: This authorization is good until the following date(s)	or event(s)
(specify event)
A photocopied or faxed version of this authorization is as valid as the original.
I have had an opportunity to review and understand the content of this authorization form. By signing this authorization, I am confirming that it accurately reflects my wishes.
9.	Signatures:
Member:
Date:
If an “X” is used:
Date:
Witnessed By
Legal Authority:
Date:
Legal Authority:	Legal Guardian
Executor of Estate of Deceased
Activated Power of Attorney
Legal Authority Has Presented Documentation That Member Is:
Legally Incompetent (Court Documents)
Deceased (Death Certificate)
Legally Incapacitated (appropriate documentation as required by law to activate
Power of Attorney–Health Care)

WDVA 4002 (07/15) Page 2 of 2	You can print the most recent version of this form Templates\WDVA_4002_Authorization_for_Disclosure_of_Health_Information.dotx	from the WDVA website at http://dva.state.wi.us/Pages/newsmedia/WDVAToolkit.aspx

WDVA 4002 (07/15) Page 1 of 2	You can print the most recent version of this form from the WDVA

Templates\WDVA_4002_Authorization_for_Disclosure_of_Health_Information.dotx	website at http://dva.state.wi.us/Pages/newsmedia/WDVAToolkit.aspx

WDVA 4002 - Authorization for Disclosure of Health Information

Matt Niehaus

2018-07-20

Niehaus, Matt

Department of Veterans Affairs