Authorization for Release of Confidential Information

(Complete in full. See reverse side for instructions.)

1. Regarding Student
   | ___________________________________________________________________
   Name - Last, First, MI
   ___________________________________________________________________
   Street Address Telephone #
   ___________________________________________________________________
   City State Zip Code
   ___________________________________________________________________
   Birth Date Student ID #
   
2. Records Released From:
   _________________________________________
   Name - (i.e. Health Facility, Physician)
   _________________________________________
   Street Address
   _________________________________________
   City State Zip Code
   
3. Records Released To:
   ___________________________________________
   Name - (McBurney Center, self, Physician...)
   ___________________________________________
   Street Address
   ___________________________________________
   City State Zip Code
   
4. Information to be Released: (check all applicable categories)
   [ ] All Clinic Records [ ] Educational/Psychological Reports [ ] Telephone/Oral Communication
   [ ] Clinic Records pertaining to inpatient/outpatient treatment of: (Specify approximate date(s) or condition)
   ___________________________________________________________________
   ___________________________________________________________________
   [ ] Other (specify)__________________________________________________
   _________________________________________________________________
   For the Following Dates:_____________________________________________
   In compliance with Wisconsin Statutes which require special permission to release otherwise privileged information, please release records pertaining to: (check applicable conditions) [ ] Mental Health [ ] Developmental Disabilities [ ]Alcohol Treatment/Evaluation
   [ ] Aids/Aids-Related Illness [ ] Drug Treatment/Evaluation [ ] HIV Test Results
   
5. Purpose or Need for Disclosure: (check applicable categories)
   [ ] Disability Services Eligibility Determination [ ] Advocacy/Liaison [ ] Counseling [ ]Other_____________
   
6. This authorization will remain in effect until: (See reverse side for further information) _____________________
   
7. I authorize release of my medical/educational records in accordance with the specification listed above. I understand written notification is necessary to cancel this request.
8. Signature of student/client________________________________________Date______________
   (If signed by someone other than student, state relationship and authority to do so. See below for signing authority.)
   

NOTE TO RECIPIENT OF INFORMATION: This information has been disclosed to you from confidential records, which are protected by law. Unless you have further authorization, laws may prohibit you from making any further disclosure of this information without the specific written consent of the individual involved.

ADDITIONAL INFORMATION REGARDING RELEASE OF CONFIDENTIAL INFORMATION

The McBurney Disability Resource Center recognizes a student's right to confidentiality of medical records as set forth by Wisconsin Statutes. Therefore, the students should be aware of the following guidelines when requesting medical records. The numbers listed below correspond to the numbered sections on the authorization form.

6. Wisconsin Statues recognize the need for informed consent. The patient may request multiple releases of the information stated on the authorization form. However, all releases based on this form are limited to records dated up to and including the patient's signature. A new authorization is necessary for release of information on care provided after the patient's signature, unless it is stated in the authorization to release "future records of a specific test, specified clinic appointment and/or admissions with the month and year identified".
   
7. Generally, all patients 18 years of age and older must sign for release of their records. Read the following to determine exceptions for patients older or younger that 18 years.
   * All patients 18 years of age and older must sign for release of their own medical records unless the following conditions apply:
   
   • The patient is incompetent.
   • The patient is disabled and cannot sign the form.
   • The patient is deceased. (The surviving spouse or legal representative must sign authorizations releasing records for the deceased patient.)
   * Patients less that 18 years of age must sign for release of their medical records when:
   
   • The patient is 14 years of age or older and the records involve treatment for mental illness, alcoholism or drug dependence.
   • The patient's record for release includes abortion procedures.
   * All persons signing for release of records, instead of the patient, must state their relationship to the patient and have available proof of legal authority to release the records.
   
   Patient is: ___Minor ___Incompetent ___Disabled ___Deceased
   
   Legal Authority: ___Legal Guardian ___Parent of Minor ___Next of Kin Deceased ___Health Care Power of Attorney