Wisconsin Doc 1163 Form – Fill Out and Use This PDF

Under INDIVIDUAL/AGENCY BEING AUTHORIZED TO RELEASE INFORMATION/RECORD(S), enter the name of the individual or agency, the telephone number, fax number, address, city, state and zip code.

Under SUBJECT OF INFORMATION/RECORD(S), enter the name, identifying/DOC number, date of birth and address.

Under INFORMATION/RECORD(S) MAY BE RELEASED TO, enter the name of the individual or agency, the telephone number, fax number, address, city, state and zip code.

Do not use this form to authorize disclosure of protected health information. Use form DOC-1163A.

Under SPECIFIC INFORMATION AUTHORIZED FOR DISCLOSURE, check all that apply.

For the 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.

For the Division of Community Corrections File, use DOC-1163A for disclosure of any health information.

Two-way Release: by checking this box, you 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) checked on this form, on an ongoing basis for the duration of this authorization.

The information authorized 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.

Under EDUCATION, identify the time period of records.

Education records include regular education information/records (including attendance records), a high school transcript, GED or HSED scores and a vocational/technical school or college transcript.

Under EMPLOYMENT, identify the time period of records. Period(s) of employment, job performance evaluation(s), job attendance, job duties & title.

Signing of Authorization on DOC-1163: you are under no legal obligation to sign this authorization. If you do, you have a right to receive a copy.

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

If you 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 you, a court order or other specific authorization under the law. However, if you consent to release education information/record(s) to an individual/agency not covered by federal or state laws that prohibit re-disclosure, your private information/record(s) may not remain confidential.

You have the right to inspect and copy your educational records as permitted under 118.125 Wis. Stats. You may be charged a reasonable fee for copies.

Initial one only (Required): the authorization expires as of a date, a number of months from the date you sign this authorization, after the following action takes place, or 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.

By signing, you confirm that you have read or had read to you the contents of this authorization, had an opportunity to discuss and ask questions, and that it accurately reflects your wishes regarding disclosure of confidential information.

The other person legally authorized to consent to disclosure, if applicable, enters the title or relationship to the individual who is subject of record and the date signed.