Voluntary and Informed Consent for Workers' Compensation - Wisconsin 2026

1. Click ‘Get Form’ to open it in the editor.
2. Begin by entering the Health Care Provider's Name and Address at the top of the form. This information is crucial for identifying who will be disclosing the medical records.
3. Next, fill in the Patient's (Employee's) Name, Social Security Number, and Birth Date. Ensure accuracy as this information links directly to your workers' compensation claim.
4. Indicate the Employer's Name to clarify which employer is associated with the claim.
5. Select one of the options under 'CHECK ONE' to specify whether you authorize the release of Physical Only records or both Physical and Other records. This choice determines what type of health information can be disclosed.
6. Sign and date the document at the bottom. If someone else is signing on behalf of the patient, provide their name and authority designation.

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