DEPARTMENT OF CORRECTIONSDivision of Management ServicesDOC-1163A (Rev. 3/04)

WISCONSINWisconsin Statutes

Sections 146.82, 146.83 and 51.30Federal Regulations

42 CFR Part 242 CFR Parts 160 & 164

AUTHORIZATION FOR USE AND DISCLOSURE OF PROTECTED HEALTH INFORMATION (PHI)INDIVIDUAL/AGENCY/ORGANIZATION BEING AUTHORIZED TO DISCLOSE PHI

NAME OF INDIVIDUAL/ORGANIZATION/AGENCY

     ADDRESS CITY STATE ZIP CODE

                       SUBJECT OF PROTECTED HEALTH INFORMATION

NAME DOC NUMBER DATE OF BIRTH

Arne J. Faaren Retired employee 05/05/1958

ADDRESS CITY STATE ZIP CODE

671 Parkview Dr. New Richmond WI 54017

PHI MAY BE DISCLOSED TO

NAME OF INDIVIDUAL/ORGANIZATION/AGENCY TELEPHONE NUMBER

Arne J. Faaren Home 715-246-7441 Cell 715-410-5955

ADDRESS CITY STATE ZIP CODE

671 Parkview Dr. New Richmond WI 54017SPECIFIC INFORMATION AUTHORIZED FOR DISCLOSURE

INSTRUCTIONS: Protected Health Information (PHI) includes information created by or under the supervision of a health care provider in any format including written, electronic and verbal. Under each category of health information selected below, indicate the time-period of the PHI. In the row below each category selected, check the type(s) of PHI to be disclosed. Based upon this authorization, the health care provider may forward copies of documents and verbally discuss the PHI with the authorized recipient.

TWO WAY DISCLOSURE OF PHI

By checking this box, I authorize the individual/agency/organization(s) named above, to DISCLOSE TO EACH OTHER, only the PHI identified below on an ongoing basis until the expiration of this authorization.

MEDICAL (Physical Health)

MEDICAL CONDITION(S)

Any records of inocculations regarding hepatitus (A,B,C) Tetanus etc. received while employed at the St. Croix correctional Center, Green Bay correctional, or Fox Lake correctional

Time Period of PHI: 10/26/2013- 12/31/2013

Description of PHI diagnosis/prognosis progress notes/summaries treatment/health care plan(s)

medications laboratory reports/x-rays physician’s orders other: shots, innoculations recieved PSYCHOLOGICAL

Time Period of PHI:      

Description of PHI assessment/diagnosis treatment plan(s) progress notes/summaries *psychotherapy notes other:       * If psychotherapy notes box is checked, this form cannot be used to release any other PHI.

PSYCHIATRIC

Time Period of PHI:      

Description of PHI assessment/diagnosis treatment plan(s) progress notes/summaries other:      ALCOHOL AND DRUG INFORMATION

Time Period of PHI:      

Description of PHI assessment/diagnosis treatment plan(s) progress notes/summaries other:      AODA INFORMATION IDENTIFIED ABOVE MAY BE USED FOR:

ch. 980 special purpose evaluation (DOC/DHFS or contract evaluator)

ch. 980 court proceeding (Department of Justice, circuit court and district attorney with jurisdiction, and defense attorney)

treatment by DHFS if committed under ch. 980

DEVELOPMENTAL DISABILITY

Time Period of PHI:      

Description of PHI assessment/diagnosis treatment plan(s) progress notes/summaries other:       HIV AND AIDS

Continued

Time Period of PHI:      Description of PHI HIV test results treatment plan(s) progress notes/summaries other:      

LOCATION: I authorize the disclosure of my location knowing that this disclosure will reveal that I am in a treatment facility.

OTHER

Time Period of PHI:      

Description of PHI:      

PURPOSE OR NEED FOR DISCLOSURE OF PROTECTED HEALTH INFORMATION (check applicable category)

Treatment/Care coordination Disability determination Review by subject of PHI

Provision of PHI to outside parties Legal proceedings Other      

YOUR RIGHTS WITH RESPECT TO THIS AUTHORIZATION

General Statement of Rights. Federal and state laws protect the confidentiality of my PHI including but not limited to s. 51.30, Stats., Mental Health Act; ss. 146.82 -.83, WI Stats., Miscellaneous Health Provisions; 42 CFR Part 2, relating to AODA information; and 42 CFR Parts 160 and 164, Health Insurance Portability and Accountability Act (HIPAA).

Right to Receive Copy of This Authorization. I have a right to receive a copy of this form after I sign it.

Right to Refuse to Sign This Authorization. I am under no legal obligation to sign this form and that DOC may not condition treatment or payment based on my decision to sign this authorization except regarding research-related treatment and provision of health care that is solely for the purpose of creating PHI (Protected Health Information) for disclosure to a third party.

Right to Withdraw This Authorization. I have the right to withdraw this authorization at any time by providing a written statement of withdrawal to the individual/agency authorized to disclose PHI. My withdrawal of consent will not be effective until the individual/agency authorized to disclose PHI receives it, and will not be effective regarding the uses and/or disclosures of my PHI made prior to receipt of my withdrawal statement.

Re-disclosure. If I authorize release of PHI to an individual or agency not covered by federal or state laws that prohibit re-disclosure, my PHI may not remain confidential.

Right to Inspect and/or Copy PHI. I have the right to inspect and receive copies of my PHI as permitted by law. I may be charged a reasonable fee for these copies.

HIV Test Results. My HIV test results may be released under this authorization as well as without my authorization as described in HIV Information Regarding Testing and Disclosure POC-11, available to me upon my request.

Legal Right of Minor to Sign Authorization. A minor is a person under the age of 18 years. Medical: A parent/guardian/custodian of a minor must sign. Mental health: A parent/guardian/custodian must sign for a minor under 14 years of age and may sign for a minor aged 14-17 years. A minor 14-17 years may sign a authorization without consent of a parent/guardian and may object to access by the parent/guardian/custodian. AODA: A parent/guardian must sign for a minor under 12 years of age. Only the minor aged 12-17 years may sign; a parent/guardian lacks authority (42 CFR Part 2).

AUTHORIZATION SIGNATURE

INITIAL ONE ONLY (Required)Authorization expires as of 01/31/2013 . (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.)

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 my PHI.SIGNATURE OF INDIVIDUAL WHO IS SUBJECT OF PHI DATE SIGNED

SIGNATURE OF OTHER PERSON LEGALLY AUTHORIZED TO CONSENT TO DISCLOSURE (If Applicable)

TITLE OR RELATIONSHIP TO INDIVIDUAL WHO IS SUBJECT OF PHI

DATE SIGNED

     LIST OF DOCUMENTS/INFORMATION DISCLOSED BASED UPON THIS AUTHORIZATION

(Attach additional sheets if needed, include name and DOC number on each sheet)

INITIALS OF PERSON DISCLOSING PHI DATE DISCLOSED TIME DISCLOSED

     

FACSIMILE OR PHOTOCOPY MAY BE TREATED AS ORIGINALDISTRIBUTION: Original- Individual/Agency/Organization authorized to disclose PHI; Copy-Offender/Other Person Signing Release;

Copy- Appropriate Offender Health Care Record