P.l. 104-191 - Hipaa Privacy Authorization For Use Or Disclosure

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DEPARTMENT OF HEALTH SERVICES
STATE OF WISCONSIN
Division of Health Care Access and Accountability
P.L. 104-191
F-13153 (07/08)
WISCONSIN CHRONIC DISEASE PROGRAM (WCDP)
HIPAA PRIVACY AUTHORIZATION FOR USE OR DISCLOSURE
The Privacy Rule standards of the Health Insurance Portability and Accountability Act of 1996 (HIPAA) P.L. 104-191 require DHS, as
a covered entity, to implement processes that give patients certain rights regarding individually identifiable health information. The
information requested on this form is needed to comply with those Privacy Rule requirements.
Provision of the information that is requested on this form is voluntary. Although the use of this version of the form is voluntary, all of
the information outlined on this form is mandatory.
Personally identifiable information requested on this form is mandatory in order to process your request and will only be used for this
purpose.
INSTRUCTIONS: Mail this completed form to the following address:
WCDP
Member Services
PO Box 6410
Madison WI 53716
You are entitled to a copy of this authorization after you sign it.
SECTION I ― MEMBER INFORMATION
Name ― Last, First, Middle Initial
WCDP Identification Number
Address ― Street, City, State, ZIP Code
Telephone Number
(
)
SECTION II ― THE USE AND / OR DISCLOSURE BEING AUTHORIZED
Purpose of the use or disclosure: Describe the purpose of the requested use or disclosure.
Health Information to be used or disclosed: Please specifically describe the health information records and the dates of the
records you are authorizing be used and/or disclosed.
Person or Organization I Authorize to Disclose Health Information: Name or specifically identify the persons or organizations,
including the Wisconsin Chronic Disease Program (WCDP), who you are authorizing to disclose the health information described
above. Please include the address and telephone number for persons and/or organizations other than the WCDP.
Name
Telephone Number
(
)
Address
Name
Telephone Number
(
)
Address
Continued

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