Wisconsin Doc 1163 Form PDF Details

The Wisconsin Doc 1163 form is used to request a taxpayer identification number (TIN) from the IRS. This form can be used by individuals or businesses in order to file their tax returns. The TIN is a unique nine-digit number that is assigned to taxpayers by the IRS. It is important to have a TIN in order to file your taxes, so be sure to fill out this form if you need one.

QuestionAnswer
Form NameWisconsin Doc 1163 Form
Form Length2 pages
Fillable?No
Fillable fields0
Avg. time to fill out30 sec
Other namesdepartment of corrections forms, wi doc non health online, wi authorization confidential information printable, wisconsin doc authorization confidential

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DEPARTMENT OF CORRECTIONS

WISCONSIN

Division of Management Services

Wisconsin Statutes - Sections 19.35, 19.36

& 118.125

DOC-1163 (Rev. 3/2015)

Federal Regulations 42 CFR Part 2 & 45 CFR Parts

160 & 164

AUTHORIZATION FOR DISCLOSURE OF NON-HEALTH

CONFIDENTIAL INFORMATION

NOTICE: DO NOT USE TO AUTHORIZE DISCLOSURE OF PROTECTED HEALTH INFORMATION. USE FORM DOC-1163A

INDIVIDUAL/AGENCY BEING AUTHORIZED TO RELEASE INFORMATION/RECORD(S)

NAME OF INDIVIDUAL / AGENCY

 

 

TELEPHONE NUMBER

FAX NUMBER

 

 

 

 

 

 

ADDRESS

 

CITY

STATE

ZIP CODE

 

 

 

 

 

 

SUBJECT OF INFORMATION/RECORD(S)

 

 

NAME

ADDRESS

IDENTIFYING/DOC NUMBER

DATE OF BIRTH

CITY

STATE

 

ZIP CODE

 

 

 

 

 

INFORMATION/RECORD(S) MAY BE RELEASED TO

NAME OF INDIVIDUAL / AGENCY

 

TELEPHONE NUMBER

FAX NUMBER

 

 

 

 

 

ADDRESS

CITY

 

STATE

ZIP CODE

 

 

 

 

 

SPECIFIC INFORMATION AUTHORIZED FOR DISCLOSURE

INSTRUCTIONS: Check All That Apply

Institution Social Service File (Use DOC-1163A for disclosure of information relating to therapy/counseling provided by a social worker or any other health information.)

Legal

Division of Community Corrections File (Use DOC-1163A for disclosure of any health information.)

Two-way Release By checking this box I authorize the individual/agency named in this authorization, to RELEASE TO EACH OTHER, only the information/records listed for release on this form in the category(ies) below. I authorize this exchange of information on an ongoing basis for the duration of this authorization.

I understand that the information I am authorizing for release may contain Personally Identifiable Information (PII) such as complete date of birth, driver’s license number, state ID number or social security number.

Check the category(ies) and sub-categories of information authorized for release.

EDUCATION

Identify Time Period Of Records:

Regular education information/records (including attendance records)

High School Transcript

Other:

SPED information/record(s) e.g. IEP, MMPI, M-Team, etc.

GED or HSED Scores

High school credits

Disciplinary Actions

Vocational/technical school or college transcript

Purpose: To assist in educational/vocational planning

Purpose: To complete PSI

Other:

EMPLOYMENT

Identify Time Period Of Records:

 

 

Period(s) of employment

Job performance evaluation(s)

Purpose:

To assist in career planning

Other

Job attendance

Job duties & title

CONTINUED

DOC-1163 CONTINUED

Purpose:

To complete PSI

 

 

OTHER

Identify Time Period Of Records:

Type(s) or information/record(s):

Purpose:

YOUR RIGHTS WITH RESPECT TO THIS AUTHORIZATION

Signing of Authorization - I am under no legal obligation to sign this authorization. If I do, I have a right to receive a copy.

AODA Information - My educational information/record(s) may contain alcohol and other drug abuse information. If so, I must sign DOC-1163A or that information will be redacted before the education information/record(s) are released.

Re-disclosure of Education Information/Record(s) - If I authorize release of education information/record(s) to an individual or agency covered by federal or state laws that prohibit re-disclosure, the recipient cannot re-disclose the information/records without a signed information release from me, a court order or other specific authorization under the law . However, if I consent to release education information/record(s) to an individual/agency not covered by federal or state laws that prohibit re-disclosure, my private information/record(s) may not remain confidential.

Right to Inspect and/or Copy Education Information/Records - I have the right to inspect and copy my educational records as permitted under s. 118.125 Wis. Stats. I may be charged a reasonable fee for copies.

 

 

AUTHORIZATION SIGNATURE

INITIAL ONE ONLY (Required)

 

 

Authorization expires as of:

, (Date)

 

 

Authorization expires:

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

 

Authorization expires after the following action takes place:

Authorization expires upon substantial change in criminal justice system status. (e.g., released from prison.)

If no date/event is entered, this Authorization expires one year from the date of signing.

I have read or had read to me the contents of this authorization. I have had an opportunity to discuss and ask questions. By signing this authorization, I am confirming that it accurately reflects my wishes regarding disclosure of confidential information.

SIGNATURE OF INDIVIDUAL WHO IS SUBJECT OF RECORD

 

DATE SIGNED

 

 

 

SIGNATURE OF OTHER PERSON LEGALLY AUTHORIZED

TITLE OR RELATIONSHIP TO INDIVIDUAL WHO IS

DATE SIGNED

TO CONSENT TO DISCLOSURE (If Applicable)

SUBJECT OF RECORD

 

 

 

 

FAX OR PHOTOCOPY MAY BE TREATED AS ORIGINAL

DISTRIBUTION: Original- Individual/Agency authorized to release Information/Record(s); Copy-Offender/Other Person Signing Release;

Official Record-Appropriate Offender Education/Legal File, Right Side/Social Service File, Left Side

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