WEST ALLIS FIRE DEPARTMENT
INFORMED CONSENT FOR DISCLOSURE OF PATIENT HEALTH CARE INFORMATION
CHAPTER 145, WISCONSIN STATUTES
I, ______________________________ born on __________________________________
(Name of Patient) (Date of Birth)
authorize the City of West Allis Fire Department, through its officials and em
ployees, to disclose to
_____________________________________________.
(Specify Individual, Agency, Organization, etc.)
information from my health care records, maintained by the Department, and to provide copies of
same. I understand that the specific type of information to be disclosed includes:
__________________________________________________________________________________
__________________________________________________________________________________
_________________________________________________________________________________
and that this disclosure is being made for the following purpose(s): ___________________________
_________________________________________________________________________________
A photocopy of this Informed Consent for Disclosure document may be accepted in lieu of an original.
I release the City of West Allis Fire Department, its officials and employees, from all legal
responsibility or liability in connection with the disclosure of the health care information which I have
requested.
I understand that I may revoke this consent at any time, except to the extent that action has already
been taken in reliance on it. Unless revoked, this consent will remain in force until:
Patient signature and date: _________________________________________________
Person authorized by patient and date: ________________________________________
Relationship to patient: ____________________________________________________
Note: Person authorized by the patient means the parent, guardian or legal custodian of a minor
patient, the guardian of a patient adjudged incompetent, the personal representative or spouse of a
deceased patient or any person authorized in writing by the patient. If no spouse survives a deceased
patient, an adult member of the deceased patient’s immediate family may qualify. A court appointed
temporary guardian to consent to the release of records my also qualify.
West Allis Fire Department 7332 W. National Ave. West Allis, WI 53214
414 302 8900 (p); 414 302 8927 (f)
