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Form Erd-4972 - Medical Release Authorization - State Of Wisconsin Department Of Workforce Development

Medical Release Authorization

State of Wisconsin

Department of Workforce Development

Equal Rights Division

ERD Case Number: ____________

Civil Rights Bureau

Sections 111.35 & 101.22 Wisconsin Statutes allow the Equal Rights Division to secure medical

information to investigate a complaint. Completion of this authorization is voluntary. Personal

information you provide will not be used for secondary purposes (15.04(1)(m)).

Physician or Medical Facility Name

Physician or Medical Facility Street Address

Physician or Medical Facility City

Physician or Medical Facility State

Physician or Medical Facility Zip Code

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

physical and/or mental condition from (date)___________ to (date)___________ to Equal Rights Officer

________________. The Equal Rights Officer will use this information to assist in the investigation of my

complaint that I filed with the Equal Rights Division of the Department of Workforce Development.

I authorize the physician or medical facility to pre-bill me for the information released to the Equal Rights

Division. I have been informed that I may revoke this authorization in writing at any time.

This authorization will be valid for six (6) months from the date signed below.

Name of Patient

Patient Date of Birth

Authorizing Signature

Date Signed

Patient Street Address

Patient City

Patient State

Patient Zip Code

Please mail completed authorization form to the 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

221 W Madison St Ste 218

PO Box 646

Eau Claire, WI 54703

Racine, WI 53401-0646

ERD-4972 (R. 02/2005)

Form Erd-4972 - Medical Release Authorization - State Of Wisconsin Department Of Workforce Development