Associate Health & Wellness
Authorization to View / Disclose Health Information
Personal Information
Name
Phone Number
Date of Birth
Social Security Number
Address
City
State
Zip
I authorize the use or disclosure of the above named person’s Protected Health Information as described below:
From:
Covenant Medical Center-WFH, Associate Health &
Wellness
Waterloo, Iowa
WFH-All Saints, Associate Health & Wellness
Racine, Wisconsin
WFH-St. Francis, Associate Health & Wellness
Milwaukee, Wisconsin
Marianjoy-WFH, Associate Health & Wellness
Wheaton, Illinois
WFH-Elmbrook Memorial, Associate Health & Wellness
Brookfield, Wisconsin
WFH-St. Joseph, Associate Health & Wellness
Milwaukee, Wisconsin
Other:
To:
Covenant Medical Center-WFH, Associate Health &
Wellness
Waterloo, Iowa
WFH-All Saints, Associate Health & Wellness
Racine, Wisconsin
WFH-St. Francis, Associate Health & Wellness
Milwaukee, Wisconsin
Marianjoy-WFH, Associate Health & Wellness
Wheaton, Illinois
WFH-Elmbrook Memorial, Associate Health & Wellness
Brookfield, Wisconsin
WFH-St. Joseph, Associate Health & Wellness
Milwaukee, Wisconsin
Other:
For The Purpose Of: (Check all that apply.)
View Protected Health Information Only:
Transfer of Employment
Date
Legal
Time
Insurance
Inspection
Internal Transfer of Employment
Date of Transfer:
New Department:
New Worksite:
Personal Reasons
Other:
Information To Be Viewed And/Or Disclosed:
Entire Associate Health & Wellness Record
Most Recent History & Physical Assessment
Most Recent TB (Mantoux) Skin Test Record
Titer(s):
Immunization Record(s) Please Specify:
Rubella
Rubeola
Hepatitis B Surface Antibody
Varicella
Mumps
Other: [Please be specific. If possible, make reference to a diagnosis or approximate date(s) of treatment.]
This authorization is voluntary. I understand that if I refuse to authorize the disclosure of information, the information may not
be released, except where permitted by law.
AH&W Authorization to View/Disclose
Health Information
Page 1 of 2
Rev 08/06
In support of your privacy, Wheaton Franciscan Healthcare Associate Health & Wellness will not accept your blanket
authorization to disclose Protected Health Information of treatment you have not yet received. A new authorization will be
required for each new episode of care.
I understand that I have a right to revoke this authorization at any time. I can do so by submitting my revocation in writing to
the Associate Health & Wellness department. I understand that my revocation will not apply to information that has already
been released in response to this authorization.
I understand that the information in my health record may include documentation relating to mental health, sexually
transmitted disease, Acquired Immunodeficiency Syndrome (AIDS), or Human Immunodeficiency Virus (HIV). I understand
that if I refuse to authorize the disclosure of this information, the information may not be released.
I further understand that HIV test results may be disclosed without my permission in certain circumstances and that a list of
such circumstances is available to me upon request.
I further understand that I have a right to receive a copy of any mental health treatment record to be disclosed.
This authorization expires 365 days from the date it is signed unless otherwise noted
.
Signature of Associate
Date
Signature of Authorized Representative
Date
If signed by other than associate, indicate relationship or authority:
Associate is
A minor
Incompetent
Deceased
I am
Legal Guardian
Next of Kin of Deceased
Executor of Estate
Signature of Witness
Date
If unable to sign document, give reason:
NOTE: Re-disclosure of this information may be permitted to and by individuals or organizations who are not subject to
federal health information privacy laws. Wheaton Franciscan Healthcare is subject to privacy laws, the other entity noted
above (if applicable) may not be subject to federal privacy laws.
“This information has been disclosed to you from records protected by Federal Confidentiality Rules (42 CFR Part 2). The
Federal Rules prohibit you from making any further disclosure of this information unless further disclosure is expressly
permitted by the written consent of the person to whom it pertains or as otherwise permitted by 42 CFR Part 2. A general
authorization for the release of medical or other information is NOT sufficient for this purpose. The Federal Rules restrict any
use of the information to criminally investigate or prosecute any alcohol or drug abuse patient.”
A COPY OF THIS AUTHORIZATION SHALL BE CONSIDERED AS VALID AS THE ORIGINAL.
OFFICE USE – RELEASE LOG
Requestor’s identification verified
Route of Release
Fax
Mail
Pick-Up
Associate notified of applicable fees
Records released by:
Name
AH&W Authorization to View/Disclose
Health Information
Date
Page 2 of 2
Time
Rev 08/06