Right to receive a copy of this authorization – I understand that if I sign this authorization, I will be provided with a copy of this authorization.
Right to refuse to sign this authorization – I understand that I am under no obligation to sign this form and that the person(s) and/or organizations(s) listed on the other side may not condition treatment, payment, enrollment in a health plan, or eligibility for health care benefits on my decision to sign this authorization except regarding:
research-related treatment the provision of health care that is solely for the purpose of creating protected health information for disclosure to a third party other exceptions (specify)
Right to withdraw this authorization – I understand I may cancel this authorization at any time. If I want to cancel this authorization, I must do so in writing and give the written cancellation document to the agency I authorized to release information. I understand that my cancellation will not be effective as to uses and/or disclosures of my health information that the person(s) and/or organization(s) listed herein have made prior to receipt of my cancellation form.
Right to inspect or copy the health information to be used or disclosed – I understand that I have the right to inspect or copy (may be provided at a reasonable fee) the health information I have authorized to be used or disclosed by this authorization form. Except for medication/somatic
treatment records, a director/designee of a treatment facility for mental illness, developmental disability, alcohol or drug abuse may deny that right during treatment in some circumstances. (Section 51.30 Wisconsin Stats HFS 92.03-02-06 Wisconsin Adm. Code)
Mental health treatment records – I understand that I have the right to inspect and receive a copy of my mental health treatment records to the extent required by HFS 92.05 and 92.06 of the Wisconsin Administrative Code.
Re-release of records – Chippewa County Department of Human Services will not re-release
records without a court order or client release.
Release of Information DHS (Updated 4-1-14)