WAUKESHA COUNTY DEPARTMENT OF HEALTH AND HUMAN SERVICES
RELEASE OF INFORMATION FOR BILLING PURPOSES
COUNTY/TRIBE OF
RESIDENCE
GUARDIAN / RESPONSIBLE PARTY
I hereby authorize the release of any and all information necessary to process claims for services
rendered during treatment beginning on the admission date below. I give consent to the Waukesha County Department of
Health & Human Services (WCDHHS) to disclose and release my medical and treatment records to a third-party payer, such
as my health care plan, for payment, claims reimbursement and third party appeal purposes. I understand that this may
include substance use records bound by Title 42 CFR Part 2. I also consent to the disclosure and release by WCDHHS of my
insurance eligibility and subscriber information to the Provider and/or their billing agent for medical services rendered to
me prior to (or during my involvement in) treatment services with WCDHHS. I further authorize payment directly to
WCDHHS, who accepts my assignment. This information is confidential and limited to the above purposes only.
EXPIRATION DATE: This authorization will expire 24 months following the completion of active services with WCDHHS unless
a specific date is or a written notice of revocation is submitted.
HEALTH INSURANCE WAIVER FOR NON-COVERED SERVICES: I understand that WCDHHS will bill my
commercial, Medicare, and/or Medicaid insurance as a courtesy. I understand that my health insurance may not cover
certain services provided by WCDHHS, and that I may be responsible for non-covered services. I understand that I am
responsible to pay applicable deductible, co-payment, and/or co-insurance amounts. I understand that it is my
responsibility to verify benefits with my insurance company.
UNINSURED WAIVER FOR RENDERED SERVICES: I understand that I will be responsible to pay any applicable fees
for any rendered services in accordance with Wisconsin Administrative Code DHS1.
REDSTAMP PROGRAM (MEDLIST): I understand the Redstamp Program is subject to the above statements.
Additionally, I understand that I am responsible for any copays associated with my Genoa Pharmacy prescriptions.
Signature of Patient or Power of Attorney or Guardian or Legal Representative * Date
Signature of Witness Date
* If signed by a person other than the client, complete the following:
Unable to sign due to disability
* If you check any of the above boxes, you must have proof of legal authority (i.e. Guardianship Papers, Power of Attorney documents) *
PRIMARY INSURANCE CO NAME
SECONDARY INSURANCE CO NAME
TERTIARY INSURANCE CO NAME
ADM06-0863, 8/16, Rev. 9/16, 2/17, 11/17, 11/19, 5/20, 6/20 Original to Fiscal Copy to Chart
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