Patient Name: Birth Date: Phone:
Address City State Zip
St. Croix County Dept. of Health & Human Services 1752 Dorset Lane, New Richmond, WI 54017
Individual Requesting Records:___________________________________________________________________________________________
To: Release to: Receive from: Verbally exchange with:
Individual/Organization _______________________________________________________________________________________________________________
Address City/State/Zip Phone Fax
All my treating providers from_________________________________________________________________________________________________________
Address City/State/Zip Phone Fax
All my non-treating providers from_____________________________________________________________________________________________________
Address City/State/Zip Phone Fax
In compliance with WI Statutes and federal regulations which require special permission to release otherwise privileged information,
please release records pertaining to:
Mental Health Substance Use Disorder HIV Juvenile Supervision
Sexually Transmitted Disease Developmental Disabilities Physical Disabilities Child Protection Services
Other (specify)__________________________
Information to be released: (check all that apply)
Discharge and Closing Summaries Chemical History/Assessment CPS Reports
Prescription for Treatment Admission History and Evaluations/Assessments Social History
Progress Reports/Case Notes Treatment Plans/Agreements Lab Reports
Psychiatric Evaluations (include diagnosis/prognosis) Contracted Agency Discharge/assessment Aftercare Plans
Medical Reports/Physical Exams Court Reports/Custody Studies Vocational Eval Reports
Therapy Progress Reports Psychological Tests/Evaluations School Records
Speech OT PT
For the following dates: From ____________________________________________ to ____________________________________________
The specific purpose or need for such disclosure is: (check all that apply)
Coordination of Care Obtain History Human Services investigation Other (specify)
This authorization will be effective for medical/treatment records generated to the date of signature, and the release of medical records created after the date of signature until the expiration date or the release is
revoked by me in writing. This authorization for disclosure of information has been fully explained to me and I understand it. I have been offered a copy of this form. I also understand that I may revoke this consent
at any time except to the extent that action has been taken in reliance on it and that in any event this consent expires within one year of the signing of this form, or (specify date/event)
. I understand that I am under no obligation to sign this form and that the person and/or agency listed above who I am authorizing to use and/or disclose my information may not condition treatment,
payment, enrollment in a health plan or eligibility for health care benefits on my decision to sign this authorization. The c onsent will last no longer than reasonably necessary to serve the purpose for which it is
given. The information disclosed is restricted to the minimum amount necessary to accomplish the intended purpose. The information used or disclosed may no longer be protected once it is used or disclosed in
accordance with this authorization. A copy of this consent has the same force and effect as the original. By signing this authorization, I am confirming that I have had an opportunity to review and understand the
content of this authorization form and that it accurately reflects my wishes. I AM ALSO CONFIRMING THAT I HAVE READ AND UNDERSTAND THE RIGHTS WITH RESPECT TO THIS AUTHORIZATION,
Signature of Client: Date:
Signature of Guardian/Legal Rep: Date:
If signed by a person other than the patient, complete the following:
1. Client is: Minor Incompetent Unable to sign due to disability Deceased
2. Legal Authority: Parent of Minor Legal Guardian/Representative
** All persons signing for the release of records instead of the client must state their relationship to the client and have proof of legal authority attached to this authorization before
we will release any records. (i.e. Guardianship Papers)**
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Right to Inspect or Copy the Confidential Information to be Used or Disclosed: I
understand that I have the right to inspect or copy the health of confidential information I have
authorized to be used or disclosed by this authorization form. I may arrange to inspect my health
or confidential information or obtain copies of my confidential information by contacting St. Croix
County Department of Health & Human Services Medical Records Department.
I understand that I may be charged a fee for record copies.
Right to Receive a Copy of this Authorization: I understand that if I agree to sign this
authorization, which I am not required to do, I must be provided with a signed copy of the form.
Right to Refuse to Sign this Authorization: I understand that I am under no obligation to sign
this form and that the person(s) and/or organization(s) listed who I am authorizing to use and/or
disclose my information may not condition treatment, payment, enrollment in a health plan or
eligibility for health care benefits on my decision to sign this authorization.
Right to Revoke this Authorization: I understand that I can cancel this authorization at any
time by providing a written notification to the Privacy Officer at St. Croix County Department of
Health & Human Services or to the disclosing medical records/health information department in
writing. However, I understand that my revocation will not be effective as to uses and/or
disclosures already made in reliance upon this Authorization before receipt of the written notice of
revocation; or needed for an insurer to contest a claim/policy as authorized by law if signing the
Authorization was a condition to obtaining insurance coverage.
Re-disclosure Notice: I understand that the information used and/or disclosed pursuant to this
Authorization may be subject to re-disclosure and no longer protected by federal privacy law. The
third party may not be required to abide by this Authorization or applicable Federal and State law
governing the use and disclosure of my health or confidential information.
I understand that a copy of this authorization will be considered valid as the original.
Note to Disclosing Party: As a public agency, the St. Croix County Department of Health &
Human Services is governed by the Wisconsin Open Records Law. Information the Department
receives in effect becomes part of the client’s record, just as if it were created by the Department. A
“confidential” label on a record is not sufficient to restrict client access or re-release. It can only be
protected by a specific confidentiality law, Section 19.85 (Wisconsin Statutes), or the balancing test
in the Open Records Law.
These restrictions on disclosure do not apply to communications of information between or
among St. Croix County Department of Health & Human Services personnel having a need for the
information in connection with their duties that arise out of the provision of diagnosis, treatment,
or referral for treatment of alcohol or drug abuse.
I understand that my Substance Use Disorder records are protected under the Federal
regulations governing Confidentiality and Substance Use Disorder Patient Records, 42 C.F.R. Part
2 , and Health Insurance Portability and Accountability act of 1996 (“HIPAA”), 45 C.F.R. pts 160 &
164, and cannot be disclosed without my written consent unless otherwise provided for by the
Updated April 2019