12 04 12 #2004 DOE CONSENT FOR RELEASE OF INFORMATION KCB - dsps wi-2026

1. Click ‘Get Form’ to open it in the editor.
2. Begin by entering the patient's name in the designated field. Ensure accuracy for proper identification.
3. Next, input the patient's date of birth. This is crucial for verifying the identity of the patient.
4. In the authorization section, specify the name of the individual or facility that treated the patient. Examples include 'Metropolitan Hospital' or 'Dr. Jane Doe'.
5. Fill in the date when you are signing the form to indicate when consent is granted.
6. Sign your name legibly in the signature field to validate your consent.
7. If applicable, indicate your authority for signing (e.g., parent, guardian) to clarify your relationship to the patient.
8. Finally, review all entries for accuracy before submitting. Once completed, send it to the Department of Safety and Professional Services at P.O. Box 8935, Madison, WI 53708-8935.

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