Form Mr-465-8 Nis-Authorization For Disclosure Of Health Information Form
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1
2AUTHORIZATION FOR DISCLOSURE OF
LABEL
HEALTH INFORMATION
AGNESIAN HEALTHCARE
MR-465-8 NIS (5/2/14)
ORDER FROM PRINTING
Consultants Laboratory
Fond du Lac Regional Clinic
Ripon Medical Center
St. Agnes Hospital
430 E. Division Street
420 E. Division Street
933 Newbury Street, PO Box 390
430 E. Division Street
Fond du Lac, WI 54935
Fond du Lac, WI 54935
Ripon, WI 54971
Fond du Lac, WI 54935
St. Francis Home
Waupun Memorial Hospital
Agnesian HealthCare Enterprises
33 Everett Street
620 W. Brown Street
430 E. Division Street
Fond du Lac, WI 54935
Waupun, WI 53963
Fond du Lac, WI 54935
1.
Regarding Patient/Resident
2.
Health information released to:
❑ pick-up - date: ________________________________
❑ mail
❑ Password (hospital use): ________________________________
_______________________________________________
Name - last, first, middle
_______________________________________________
Name of individual(s) / Organization
_______________________________________________
Maiden name or other name
_______________________________________________
Name of individual(s) / Organization
_______________________________________________
_______________________________________________
Street Address / P.O. Box
Street Address / P.O. Box OR Additional Name
_______________________________________________
_______________________________________________
City, State, Zip Code
City, State, Zip Code OR Additional Name
_____________________
_______________________
_______________________________________________
Telephone number
Fax number
Telephone Number
FOR PICK-UPS, PLEASE LIST WHO WILL PICK-UP RECORDS:
_______________________________________________
Birthdate
_____________________________________________________________
Name
3. PROVIDER USE – For Referral Purpose complete the following:
Diagnosis: ______________________________________________________________________________________________________
Provider: ______________________________________________________ Department: ______________________________________
❑ Froedtert
❑ Children’s Hospital of WI
❑ UW-Madison
❑ Other: ___________________________________________________
Check to send last results of:
❑ Provider Notes ______________________________________________________________________________________________
❑ Labs ______________________________________________________________________________________________________
❑ Medical Imaging Report ❑
CD ❑ ______________________________________________________________________________
❑ Pathology __________________________________________________________________________________________________
❑ Cardiology Studies (EKG/Echo/Stress Test) _______________________________________________________________________
❑ Specify other notes: __________________________________________________________________________________________
4.
I authorize the following facility to disclose the health information identified in Section 5:
❑ St. Agnes Hospital
❑ St. Francis Home
❑ Waupun Memorial Hospital
❑ Consultants Laboratory
❑ Ripon Medical Center
❑ Agnesian HealthCare Enterprises
___________________________________________________________________
❑ Fond du Lac Regional Clinic, site location:
____________________________________________________________________________________________
❑ Other:
____________________________________________
_____________________________________________
Street
City, State, Zip Code
(CONTINUED ON BACK)
Fax form to:
❑ ROI: (920) 926-8910
❑ Medical Imaging (Films): (920) 926-4868
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