Form Erd-4972 - Medical Release Authorization printable pdf download

Form Erd-4972 - Medical Release Authorization

ERD CASE NO:__________________

Wisconsin Department of

Workforce Development

Equal Rights Division

MEDICAL RELEASE AUTHORIZATION

(ss. 111.35 and 101.22, Wis. Stats.)

The information you provide may be used by other government agency programs [Privacy law, s. 15.04 (1) (m)].

Physician or Medical Facility Name:

Physician or Medical Facility Mailing Address:

Telephone Number:

I give my permission to the above named physician or medical facility to release information regarding

the physical and/or mental condition, past or present, of the patient named below, to an Equal Rights

Officer. This authorization is to be used to assist in the investigation of a complaint filed with the Equal

Rights Division of the Department of Workforce Development.

I also authorize the physician or medical facility to pre-bill me for copies of my medical records

released to the Equal Rights Division.

These authorizations will be valid for six (6) months from the date signed below.

Name of patient:

Patient’s date of birth:

Authorizing Signature:_________________________________________________________

Mailing Address:

_________________________________________________________

Date Signed:

______________________________

Completion of this authorization is voluntary.

Please mail completed authorization form to Equal Rights Division address checked below.

PO Box 8928

819 N. 6th St., #255

1802 Appleton Road

Madison, WI 53708

Milwaukee, WI 53203

Menasha, WI 54952

PO Box 885

PO Box 646

129 River Dr.

Eau Claire, WI 54702

Racine, WI 53401-0646

Wausau, WI 54403-1067

ERD-4972 (R. 01/1999)

Form Erd-4972 - Medical Release Authorization