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DEPARTMENT OF CORRECTIONS Division of Management Services DOC-1163A Rev!

3"#$%

WISCONSIN &isconsin Stat'tes Sections 1$6!()* 1$6!(3 an+ ,1!3# Fe+era- Reg'-ations $) CFR Part ) $) CFR Parts 16# . 16$

AUTHORIZATION FOR USE AND DISCLOSURE OF PROTECTED HEALTH INFORMATION (PHI)


INDIVIDUAL/AGENCY/ORGANIZATION BEING AUTHORIZED TO DISCLOSE PHI
NAME OF INDI/ID0A1"OR2ANI3ATION"A2ENC4

ADDRESS CIT4 STATE 3IP CODE

NAME

SUBJECT OF PROTECTED HEALTH INFORMATION


DOC N0M5ER

DATE OF 5IRT6

Arne J. Faaren
ADDRESS

Retired employee
CIT4

05/05/1958
STATE 3IP CODE

671 Parkview Dr.

ew Ri!"mond
PHI MAY BE DISCLOSED TO

#$

5%017

NAME OF INDI/ID0A1"OR2ANI3ATION"A2ENC4

TE1EP6ONE N0M5ER

Arne J. Faaren
ADDRESS CIT4

&ome 715'(%6'7%%1 )ell 715' %10'5955


STATE 3IP CODE

671 Parkview Dr.


INSTRUCTIONS7

ew Ri!"mond
SPECIFIC INFORMATION AUTHORIZED FOR DISCLOSURE

#$

5%017

Protecte+ 6ea-t8 Information P6I% inc-'+es information create+ 9: or 'n+er t8e s';ervision of a 8ea-t8 care ;rovi+er in an: format inc-'+ing <ritten* e-ectronic an+ ver9a-! 0n+er eac8 categor: of 8ea-t8 information se-ecte+ 9e-o<* in+icate t8e time-;erio+ of t8e P6I! In t8e ro< 9e-o< eac8 categor: se-ecte+* c8ec= t8e t:;e s% of P6I to 9e +isc-ose+! 5ase+ ';on t8is a't8ori>ation* t8e 8ea-t8 care ;rovi+er ma: for<ar+ co;ies of +oc'ments an+ ver9a--: +isc'ss t8e P6I <it8 t8e a't8ori>e+ reci;ient! TWO WAY DISCLOSURE OF PHI 5: c8ec=ing t8is 9o?* I a't8ori>e t8e in+ivi+'a-"agenc:"organi>ation s% name+ a9ove* to DISC1OSE TO EAC6 OT6ER* on-: t8e P6I i+entifie+ 9e-o< on an ongoing 9asis 'nti- t8e e?;iration of t8is a't8ori>ation!

MEDICAL (Physi !" H#!"$h)

MEDICA1 CONDITION S% Time Perio+ of P6I7 Descri;tion of P6I PSYCHOLOGICAL Time Perio+ of P6I7 Descri;tion of P6I PSYCHIATRIC Time Perio+ of P6I7

Any re!ord* o+ ino!!,lation* re-ardin- "epatit,* .A/0/)1 2etan,* et!. re!eived w"ile employed at t"e 3t. )roi4 !orre!tional )enter/ 5reen 0ay !orre!tional/ or Fo4 6ake !orre!tional
10/(6/(017' 1(/71/(017
+iagnosis";rognosis ;rogress notes"s'mmaries treatment"8ea-t8 care ;-an s% me+ications -a9orator: re;orts"?-ra:s ;8:sician@s or+ers ot8er7 *"ot*/ inno!,lation* re!ieved

assessment"+iagnosis ot8er7 treatment ;-an s% ;rogress notes"s'mmaries

%&sy h'$h#(!&y )'$#s

A If &sy h'$h#(!&y )'$#s *'+ is h# ,#-. $his /'(0 !))'$ *# 1s#- $' (#"#!s# !)y '$h#( PHI !

treatment ;-an s% ;rogress notes"s'mmaries ot8er7

assessment"+iagnosis Descri;tion of P6I ALCOHOL AND DRUG INFORMATION


Time Perio+ of P6I7

;rogress notes"s'mmaries ot8er7

assessment"+iagnosis treatment ;-an s% Descri;tion of P6I AODA INFORMATION IDENTIFIED ABOVE MAY BE USED FOR2
c8! B(# s;ecia- ;'r;ose eva-'ation DOC"D6FS or contract eva-'ator%

c8! B(# co'rt ;rocee+ing De;artment of C'stice* circ'it co'rt an+ +istrict attorne: <it8 D'ris+iction* an+ +efense attorne:% treatment 9: D6FS if committe+ 'n+er c8! B(# DEVELOPMENTAL DISABILITY Time Perio+ of P6I7

)ontin,ed

Descri;tion of P6I HIV AND AIDS Time Perio+ of P6I7 Descri;tion of P6I

assessment"+iagnosis

treatment ;-an s%

;rogress notes"s'mmaries

ot8er7

6I/ test res'-ts treatment ;-an s% ;rogress notes"s'mmaries ot8er7

LOCATION2 I a't8ori>e t8e +isc-os're of m: -ocation =no<ing t8at t8is +isc-os're <i-- revea- t8at I am in a treatment faci-it:! OTHER Time Perio+ of P6I7 Descri;tion of P6I7

PURPOSE OR NEED FOR DISCLOSURE OF PROTECTED HEALTH INFORMATION ( h# , !&&"i !*"# !$#3'(y) Treatment"Care coor+ination Provision of P6I to o'tsi+e ;arties Disa9i-it: +etermination 1ega- ;rocee+ings Revie< 9: s'9Dect of P6I Ot8er

YOUR RIGHTS WITH RESPECT TO THIS AUTHORIZATION


2enera- Statement of Rig8ts! Fe+era- an+ state -a<s ;rotect t8e confi+entia-it: of m: P6I inc-'+ing 9't not -imite+ to s! ,1!3#* Stats!* Menta- 6ea-t8 ActE ss! 1$6!() -!(3* &I Stats!* Misce--aneo's 6ea-t8 ProvisionsE $) CFR Part )* re-ating to AODA informationE an+ $) CFR Parts 16# an+ 16$* 6ea-t8 Ins'rance Porta9i-it: an+ Acco'nta9i-it: Act 6IPAA%! Rig8t to Receive Co;: of T8is A't8ori>ation! I 8ave a rig8t to receive a co;: of t8is form after I sign it! Rig8t to Ref'se to Sign T8is A't8ori>ation! I am 'n+er no -ega- o9-igation to sign t8is form an+ t8at DOC ma: not con+ition treatment or ;a:ment 9ase+ on m: +ecision to sign t8is a't8ori>ation e?ce;t regar+ing researc8-re-ate+ treatment an+ ;rovision of 8ea-t8 care t8at is so-e-: for t8e ;'r;ose of creating P6I Protecte+ 6ea-t8 Information% for +isc-os're to a t8ir+ ;art:! Rig8t to &it8+ra< T8is A't8ori>ation! I 8ave t8e rig8t to <it8+ra< t8is a't8ori>ation at an: time 9: ;rovi+ing a <ritten statement of <it8+ra<a- to t8e in+ivi+'a-"agenc: a't8ori>e+ to +isc-ose P6I! M: <it8+ra<a- of consent <i-- not 9e effective 'nti- t8e in+ivi+'a-"agenc: a't8ori>e+ to +isc-ose P6I receives it* an+ <i-- not 9e effective regar+ing t8e 'ses an+"or +isc-os'res of m: P6I ma+e ;rior to recei;t of m: <it8+ra<a- statement! Re-+isc-os're! If I a't8ori>e re-ease of P6I to an in+ivi+'a- or agenc: not covere+ 9: fe+era- or state -a<s t8at ;ro8i9it re-+isc-os're* m: P6I ma: not remain confi+entia-! Rig8t to Ins;ect an+"or Co;: P6I! I 8ave t8e rig8t to ins;ect an+ receive co;ies of m: P6I as ;ermitte+ 9: -a<! I ma: 9e c8arge+ a reasona9-e fee for t8ese co;ies! 6I/ Test Res'-ts! M: 6I/ test res'-ts ma: 9e re-ease+ 'n+er t8is a't8ori>ation as <e-- as <it8o't m: a't8ori>ation as +escri9e+ in 6I/ Information Regar+ing Testing an+ Disc-os're POC-11* avai-a9-e to me ';on m: reF'est! 1ega- Rig8t of Minor to Sign A't8ori>ation! A minor is a ;erson 'n+er t8e age of 1( :ears! Medical7 A ;arent"g'ar+ian"c'sto+ian of a minor m'st sign! Mental health: A ;arent"g'ar+ian"c'sto+ian m'st sign for a minor 'n+er 1$ :ears of age an+ ma: sign for a minor age+ 1$-1G :ears! A minor 1$-1G :ears ma: sign a a't8ori>ation <it8o't consent of a ;arent"g'ar+ian an+ ma: o9Dect to access 9: t8e ;arent"g'ar+ian"c'sto+ian! AODA7 A ;arent"g'ar+ian m'st sign for a minor 'n+er 1) :ears of age! On-: t8e minor age+ 1)-1G :ears ma: signE a ;arent"g'ar+ian -ac=s a't8orit: $) CFR Part )%!

AUTHORIZATION SIGNATURE

INITIAL ONE ONLY (R#41i(#-) A't8ori>ation e?;ires as of A't8ori>ation e?;ires

01/71/(017

! Date%

mont8 s% from t8e +ate I sign t8is a't8ori>ation!

A't8ori>ation e?;ires after t8e fo--o<ing action ta=es ;-ace7

A't8ori>ation e?;ires ';on s'9stantia- c8ange in crimina- D'stice s:stem stat's! e!g!* re-ease+ from ;rison!%
I h!5# (#!- '( h!- (#!- $' 0# $h# ')$#)$s '/ $his !1$h'(i6!$i')7 I h!5# h!- !) '&&'($1)i$y $' -is 1ss !)- !s, 41#s$i')s 7 By si3)i)3 $his !1$h'(i6!$i'). I !0 ')/i(0i)3 $h!$ i$ ! 1(!$#"y (#/"# $s 0y 8ish#s (#3!(-i)3 -is "'s1(# '/ 0y PHI7
SI2NAT0RE OF INDI/ID0A1 &6O IS S05CECT OF P6I DATE SI2NED

SI2NAT0RE OF OT6ER PERSON 1E2A114 A0T6ORI3ED TO CONSENT TO DISC1OS0RE If A;;-ica9-e%

TIT1E OR RE1ATIONS6IP TO INDI/ID0A1 &6O IS S05CECT OF P6I

DATE SI2NED

LIST OF DOCUMENTS/INFORMATION DISCLOSED BASED UPON THIS AUTHORIZATION (A$$! h !--i$i')!" sh##$s i/ )##-#-. i) "1-# )!0# !)- DOC )10*#( ') #! h sh##$)
INITIA1S OF PERSON DISC1OSIN2 P6I DATE DISC1OSED TIME DISC1OSED

FACSIMILE OR PHOTOCOPY MAY BE TREATED AS ORIGINAL


DISTRIBUTION2 Origina-- In+ivi+'a-"Agenc:"Organi>ation a't8ori>e+ to +isc-ose P6IE Co;:-Offen+er"Ot8er Person Signing Re-easeE Co;:- A;;ro;riate Offen+er 6ea-t8 Care Recor+