Professional Documents
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WISCONSIN &isconsin Stat'tes Sections 1$6!()* 1$6!(3 an+ ,1!3# Fe+era- Reg'-ations $) CFR Part ) $) CFR Parts 16# . 16$
NAME
DATE OF 5IRT6
Arne J. Faaren
ADDRESS
Retired employee
CIT4
05/05/1958
STATE 3IP CODE
ew Ri!"mond
PHI MAY BE DISCLOSED TO
#$
5%017
NAME OF INDI/ID0A1"OR2ANI3ATION"A2ENC4
TE1EP6ONE N0M5ER
Arne J. Faaren
ADDRESS CIT4
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!
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
A If &sy h'$h#(!&y )'$#s *'+ is h# ,#-. $his /'(0 !))'$ *# 1s#- $' (#"#!s# !)y '$h#( PHI !
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
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
AUTHORIZATION SIGNATURE
01/71/(017
! Date%
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
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