P.l. 104-191 - Hipaa Privacy Authorization For Use Or Disclosure Page 2
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2WCDP HIPAA Privacy Authorization For Use or Disclosure
Page 2 of 2
F-13153 (07/08)
SECTION II ― THE USE AND / OR DISCLOSURE BEING AUTHORIZED (Continued)
Person or Organization to Receive and Use: Name or specifically describe the persons or organizations, including addresses and
telephone numbers, to whom you are authorizing the WCDP to disclose to or let use the health information as previously described:
Name
Telephone Number
(
)
Address
Name
Telephone Number
(
)
Address
I understand that if the organization or person authorized to receive the information is not a health plan or health care provider, the
released information may no longer be protected by federal privacy regulations. State health record privacy regulations will still apply
to my health information.
SECTION III ― EXPIRATION AND REVOCATION
Expiration: This authorization will expire as follows (complete one):
On ____ / ____/ ________
(MM/DD/YYYY), or
On occurrence of the following event (which must relate to the member or to the purpose of the use or disclosure being
authorized):
Right to Revoke: I understand that I may revoke all or part of this authorization at any time by giving written notice of my revocation
to the Privacy Office information listed below. I understand that revocation of this authorization will not affect any action taken in
reliance on this authorization before receiving my written notice of revocation.
WCDP
Member Services
PO Box 6410
Madison WI 53716
SECTION IV ― SIGNATURES
I, ________________________________________, have had full opportunity to read and consider the contents of this authorization,
and I confirm that the contents are consistent with my direction to the WCDP. I understand that, by signing this form, I am confirming
my authorization that the WCDP may use or disclose to the persons or organizations named in this form the health information
described in this form. I also understand that the WCDP will not condition payment, enrollment, or eligibility for benefits in the WCDP
on the signing of this authorization.
SIGNATURE ― M
Date Signed
If this authorization is signed by a personal representative on behalf of the member, provide a copy of the documentation to
support the representation and complete the following:
Relationship to Member
Name ― Personal Representative
SIGNATURE ― Personal Representative
Date Signed
RESET FORM
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