F 82009 Form PDF Details

Embarking on a journey through the intricacies of medical and personal information release in Wisconsin necessitates an understanding of the F-82009 form, a pivotal document granted by the Department of Health Services. This form, steeped in legal underpinnings and designed with confidentiality at its core, serves as a bridge between individuals' rights to privacy and the necessity for information flow in specific scenarios. It captures essential details such as the name, address, and identifying number of the person whose records are to be released, providing a structured pathway for the authorization of such releases. Importantly, the form touches on the nuanced balance between voluntary participation and the ramifications of refusal, alongside the safeguards and limitations placed upon the redisclosure of information. It also delineates the conditions under which an authorization can be revoked, emphasizing the holder's control over their personal information. With sections dedicated to specifying the records for release, stating the purpose of such disclosure, and establishing an expiration for the authorization, the F-82009 form encapsulates a comprehensive framework designed to respect and protect individual privacy while facilitating necessary communication within the bounds of law and healthcare provision.

QuestionAnswer
Form NameF 82009 Form
Form Length1 pages
Fillable?No
Fillable fields0
Avg. time to fill out15 sec
Other namesF82009 f 82009 form

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DEPARTMENT OF HEALTH SERVICES

 

STATE OF WISCONSIN

F-82009 (07/08)

 

Sections 19.35 & 19.36, Wis. Stats.

 

 

 

CONFIDENTIAL INFORMATION

Name – Person Whose Records Will be Released (Record

Subject)

 

 

RELEASE AUTHORIZATION

 

 

 

 

 

Completion of this form authorizes the release of information described in the

 

 

 

section below called “Specific Description of Records Authorized for Release”.

 

 

 

Address

 

 

The person (record subject) whose records are released may have a right to

 

 

 

inspect and, upon paying any applicable fees, obtain a copy of the disclosed

 

 

 

City, State, Zip Code

 

 

records. Except for medication/somatic treatment records, a director/designee of a

 

 

 

 

 

treatment facility for mental illness, developmental disability, alcohol or drug abuse

 

 

 

may deny that right during treatment in some circumstances. Section 51.30, Wis.

Identifying Number (If Any)

 

Date of Birth

 

 

 

Stats., DHS 92.03-92.06 Wis. Adm. Code.

 

 

 

 

 

 

Name & Address – Agency/Organization I Authorize to Release Information

Name - Information May be Released To

 

 

 

 

 

Organization

 

 

 

 

 

 

 

Address

 

 

 

 

 

 

 

City, State, Zip Code

 

 

 

 

 

 

Specific Description of Records Authorized for Release (Include dates of records, if applicable)

Purpose or Need for Release of Information (Be Specific)

Understandings

∙This authorization is voluntary. Refusal to sign will not affect treatment, payment, enrollment or benefits eligibility except for:

No exceptions

Exceptions (specify):

∙The information that I authorize to be released may be redisclosed by the recipient of the records only if allowed by law. If information is redisclosed, the recipient of the redisclosed information may be controlled by different laws.

∙I may revoke this authorization, in writing, at any time except for information already released as a result of this authorization. The written revocation must be given to the agency/organization I authorized to release information.

∙Unless revoked, this authorization will remain in effect until the expiration time indicated below.

Choose One:

 

 

 

Authorization expires as of

(Date).

 

 

Authorization expires

month(s) from the date I sign this authorization.

 

 

 

 

 

 

 

 

Authorization expires after the following action takes place:

As evidenced by my signature, I hereby authorize disclosure of records to the person(s) or agency(s) specified above.

SIGNATURE - Person Whose Records Will be Released (Record Subject)

Date Signed

SIGNATURE - Other Person Legally Authorized to Consent to Disclosure

Title or Relationship to Record Subject

Date Signed

 

 

 

 

 

 

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1. Before anything else, while filling out the F 82009 Form, start out with the part containing following blanks:

Step no. 1 in filling out F 82009 Form

2. When this array of fields is done, you're ready add the needed specifics in Purpose or Need for Release of, Understandings This authorization, No exceptions, Exceptions specify, The information that I authorize, recipient of the redisclosed, I may revoke this authorization, given to the agencyorganization I, Unless revoked this authorization, Authorization expires as of, Date, Authorization expires months from, and Authorization expires after the so you can proceed to the 3rd stage.

Filling out segment 2 of F 82009 Form

3. This next segment is focused on As evidenced by my signature I, Date Signed, SIGNATURE Other Person Legally, Title or Relationship to Record, and Date Signed - fill in these blank fields.

Filling in segment 3 of F 82009 Form

People generally make mistakes while completing Date Signed in this section. Ensure you read twice what you type in here.

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