HIPAA Authorization Form - Wisconsin

WISCONSIN HIPAA AUTHORIZATION FOR USE AND DISCLOSURE OF PROTECTED HEALTH INFORMATION

(Comprehensive — 45 C.F.R. § 164.508, Wis. Stat. §§ 51.30, 146.82, 252.15, 942.07, and 42 C.F.R. Part 2)

1. PATIENT / INDIVIDUAL IDENTIFICATION

2. DISCLOSING PARTY (COVERED ENTITY / TREATMENT FACILITY)

Name of Health Care Provider / Facility: [____________________________]
Address: [____________________________]
Privacy Officer / HIM Department: [____________________________]
Telephone / Fax: [____________________________]

3. RECIPIENT(S) AUTHORIZED TO RECEIVE INFORMATION

4. SPECIFIC INFORMATION TO BE DISCLOSED

Check (☐) each category authorized. All categories require specific authorization under Wisconsin law.

☐ Complete medical record
☐ History and physical examination notes
☐ Discharge summaries
☐ Operative and pathology reports
☐ Laboratory results (non-HIV, non-genetic)
☐ Radiology / diagnostic imaging reports
☐ Consultation reports
☐ Medication / prescription records
☐ Immunization records
☐ Billing and claims records
☐ Other (specify): [____________________________]

Date Range of Records: From [__/__/____] to [__/__/____]

5. SPECIAL-CATEGORY RECORDS — WISCONSIN-SPECIFIC AUTHORIZATIONS

5.1 Mental Health, AODA, and Developmental Disability Treatment Records — Wis. Stat. § 51.30

I specifically authorize disclosure of mental health, alcoholism / other drug abuse ("AODA"), and/or developmental disability treatment records as defined in Wis. Stat. § 51.30(1)(b). I understand that this authorization complies with the informed-consent requirements of Wis. Stat. § 51.30(2), including:

(a) the name of the individual, agency, or organization to whom the disclosure is to be made (Section 3 above);
(b) the name of the subject individual whose treatment record is being disclosed (Section 1 above);
(c) the purpose or need for the disclosure (Section 6 below);
(d) the specific type of information to be disclosed (this Section 5.1 and any items below);
(e) the time period during which the consent is effective (Section 8 below);
(f) the date on which the consent is signed; and
(g) the signature of the individual (or legally authorized person).

Specific records authorized:

☐ Mental health treatment records (outpatient)
☐ Mental health treatment records (inpatient / hospitalization)
☐ Psychiatric medication records
☐ Alcohol / other drug abuse (AODA) treatment records
☐ Developmental disability service records
☐ Records of services from county departments under Wis. Stat. §§ 51.42 / 51.437

Patient Initials (required for § 51.30 records): [____]

5.2 Federal Substance Use Disorder Records — 42 C.F.R. Part 2

I specifically authorize disclosure of records protected under 42 C.F.R. Part 2 (federal confidentiality of substance use disorder patient records). I understand these records receive heightened federal protection in addition to Wis. Stat. § 51.30, and that the recipient is prohibited from redisclosing them without my further written consent or a court order meeting Part 2 requirements.

Patient Initials (required for 42 C.F.R. Part 2 records): [____]

5.3 HIV / AIDS Test Results — Wis. Stat. § 252.15

I specifically authorize disclosure of HIV test results and related information protected by Wis. Stat. § 252.15. I understand Wisconsin law imposes strict confidentiality on HIV test results, including criminal and civil penalties for unauthorized disclosure (Wis. Stat. § 252.15(8)–(9)).

Patient Initials (required for HIV results): [____]

5.4 Genetic Test Results — Wis. Stat. § 942.07 and GINA

I specifically authorize disclosure of genetic test results and genetic information, including disclosures otherwise prohibited under Wis. Stat. § 942.07 and the federal Genetic Information Nondiscrimination Act (GINA).

Patient Initials (required for genetic information): [____]

5.5 Psychotherapy Notes — 45 C.F.R. § 164.508(a)(2)

I specifically authorize disclosure of psychotherapy notes, which under HIPAA require a separate authorization from other PHI.

Patient Initials (required for psychotherapy notes): [____]

5.6 Reproductive / Sexually Transmitted Infection (Non-HIV) Records

☐ Yes — included ☐ No — excluded

Patient Initials (if included): [____]

6. PURPOSE OF DISCLOSURE

Disclosure is requested for the following purpose(s):

☐ Continuity of care / treatment by another provider
☐ Personal use by patient
☐ Legal proceeding — Case No.: [____________________________]
☐ Insurance / disability claim
☐ Social Security / SSI / SSDI determination
☐ Workers' compensation claim
☐ Employment / pre-employment evaluation
☐ Educational placement / IEP
☐ Research study: [____________________________]
☐ Other (specify): [____________________________]

7. RIGHT TO REVOKE

I understand that I may revoke this authorization at any time by delivering written notice of revocation to the Privacy Officer / HIM Department identified in Section 2. Revocation will be effective on receipt, except to the extent that the Disclosing Party has already acted in reliance on the authorization. Under Wis. Stat. § 51.30 and 42 C.F.R. § 2.31(a)(6), revocation does not affect disclosures already made.

8. EXPIRATION

This authorization expires on the earliest of:

(a) Specific date: [__/__/____]
(b) Specific event: [____________________________]
(c) Completion of the purpose stated in Section 6
(d) One (1) year from the date signed, if no other date or event is specified
(e) Written revocation under Section 7

9. REQUIRED HIPAA NOTICES — 45 C.F.R. § 164.508(c)(2)

9.1 Conditioning of Treatment / Payment / Enrollment / Eligibility. Except as permitted under 45 C.F.R. § 164.508(b)(4) (research-related treatment, eligibility-for-benefits determinations, etc.), the Disclosing Party may not condition my treatment, payment, enrollment, or eligibility for benefits on whether I sign this authorization.

9.2 Re-Disclosure Warning. Information disclosed under this authorization may be re-disclosed by the recipient and may no longer be protected by HIPAA or Wisconsin law. However, records protected under 42 C.F.R. Part 2 and Wis. Stat. § 51.30 may NOT be re-disclosed without further written authorization or a court order satisfying applicable law. Wis. Admin. Code ch. DHS 92 prohibits redisclosure of treatment-record information except as expressly permitted.

9.3 Right to Copy. I am entitled to receive a copy of this signed authorization.

9.4 Right to Inspect. I retain the right to inspect and copy my own records under Wis. Stat. § 146.83 and 45 C.F.R. § 164.524.

9.5 No Sale of PHI / No Marketing. The Disclosing Party will not sell my PHI and will not use it for marketing without separate written authorization.

10. SIGNATURE

I have read this authorization (or had it read to me). I understand its contents. I am signing voluntarily and authorize the use and disclosure of my Protected Health Information as described above.

Patient Signature: _______________________________________
Printed Name: [____________________________]
Date: [__/__/____]

If Signed by Personal Representative

Representative Signature: _______________________________________
Printed Name: [____________________________]
Date: [__/__/____]
Authority (check one):
☐ Parent / legal custodian of minor under Wis. Stat. § 51.30(5)
☐ Court-appointed guardian (attach Letters of Guardianship)
☐ Health care agent under Wis. Stat. ch. 155 (attach POA-HC)
☐ Personal representative of decedent's estate (attach Letters)
☐ Other (specify): [____________________________]

Witness (Required if Patient Signs by Mark)

Witness Signature: _______________________________________
Printed Name: [____________________________]
Date: [__/__/____]

11. SOURCES AND REFERENCES

• 45 C.F.R. § 164.508 — HIPAA authorization core elements
• Wis. Stat. § 146.81 — Definitions (health care provider, patient health care records)
• Wis. Stat. § 146.82 — Confidentiality of patient health care records
• Wis. Stat. § 146.83 — Patient access to records
• Wis. Stat. § 51.30 — Records: mental health, AODA, developmental disability
• Wis. Stat. § 252.15 — Restrictions on use of an HIV test
• Wis. Stat. § 942.07 — Genetic test results
• 42 C.F.R. Part 2 — Federal SUD records confidentiality
• Wis. Admin. Code ch. DHS 92 — Treatment record release rules