Authorization To Disclose Information To Disability Determination Bureau (Ddb) printable pdf download

ADDD

WHOSE Records to be Disclosed:

First

Middle

Last

Name:

SSN:

Birthday mm/dd/yyyy

A U T H O R I Z A T I O N

T O

D I S C L O S E

I N F O R M A T I O N

T O

D i s a b i l i t y D e t e r m i n a t i o n B u r e a u ( D D B )

* *

P L EA S E R E AD T H E E N TI R E F O RM , B O TH P A G E S, B EF O R E S I GN I N G B E LO W

* *

I voluntarily authorize and request disclosure (including paper, oral, or electronic interchange):

OF WHAT

All my medical records; also education records and other information

related to my ability to perform tasks. This includes specific permission to release:

All records from this facility ( including copies of medical records from other facilities if in my chart) regarding my treatment,

hospitalization, and/or outpatient care for my impairment(s) including, but not limited to:

— Psychological, psychiatric or other mental impairment(s) (excludes "psychotherapy notes" as defined in 45 CFR 164.501

— Drug abuse, alcoholism, or other substance abuse

— Sickle cell anemia or Gene-related impairments (including information from genetic test results and/or screenings);

— Human immunodeficiency virus (HIV) infection (including acquired immunodeficiency syndrome (AIDS) or tests for HIV) or sexually

transmitted diseases

Information about how my impairment(s) affects my ability to complete tasks and activities of daily living and affects my ability to work.

Copies of educational tests or evaluations, including Individualized Educational Programs, psychological or speech evaluations, and

any other records that can help evaluate function; also teachers’ observations and evaluations.

Information created within 12 months after the date of this authorization is signed, as well as past information.

FROM WHOM

∙ All medical sources (hospitals, clinics, labs,

∙ All educational sources (schools, teachers,

physicians, psychologists, etc.) including

records administrators, counselors, etc.)

mental health, correctional, addiction

∙ Consulting examiners used by DDB

treatment, and VA health care facilities

∙ Others who may know about my condition

∙ Social workers/rehabilitation counselors

(family, neighbors, friends, public officials)

∙ Employers

The Disability Determination Bureau, Division of Health Care Access and Accountability, Department of Health Services,

TO WHOM

State of Wisconsin which is authorized to process my case, and which includes contract copy services, and doctors or other

professionals consulted during the process.

PURPOSE

Determination of Medicaid - Disability Applications or Katie Beckett Medicaid Applications

∙ I authorize the use of a copy (including electronic copy) or facsimile (FAX) of this form for the disclosure of the information described above.

∙ I understand that there are some circumstances where this information may be redisclosed to other parties (see page 2 for details).

∙ I may write to DDB and my sources to revoke this authorization at any time (see page 2 for details).

∙ DDB will give me a copy of this form if I ask; I may ask the source to allow me to inspect or get a copy of material to be disclosed.

• I understand I have the right to review or request copies of the released material, and that the confidentiality of my records is protected by law.

• I have read both pages of this form and agree to the disclosures above from the types of sources listed.

EXPIRES WHEN

This authorization is good for 12 months from the date signed below my signature.

INDIVIDUAL authorizing disclosure:

IF not signed by subject of disclosure, specify basis for authority to sign

SIGN ►

(parent/guardian sign here if two signatures required by State law):

[ ] Parent of minor

[ ] POA for Health Care (provide POA papers)

[ ] Legal Guardian (must provide court appointed papers)

[ ] Other personal representative (explain)________________________

_____________________________________________

DATE _____________________________

Phone Number (with area code)

Street Address

City

State

ZIP

WITNESS:

I know the person signing this form or am satisfied of this person's identity:

SIGN ►

IF needed, second witness sign here (e.g., if signed with "X" above):

SIGN ►

Phone Number (or Address)

This general and special authorization to disclose was developed to comply with the provisions regarding disclosure of medical, educational, and other information under: P.L.104-

191 (“HIPAA”); 45 CFR parts 160 and 164; 42 U.S. Code section 290dd-2; 42 CFR part 2; 38 U.S. Code section 7332; 38 CFR 1.475; 20 U.S. Code section 1232g (“FERPA”); 34

CFR parts 99 and 300; and the Public Health Service Act, Sect. 523 and 527, USC Veterans Benefits, Section 4132, and State of Wisconsin Statutes Sections 19.35 & 19.36,

Section 51.30, & HFS 92.03-92.06 Wis. Adm. Code.

Form F-14014 (04/13)

State of Wisconsin, Department of Health Services

Page 1 of 2