DOC-1163A Authorization for Use and Disclosure of Protected Health Information (PHI) (2) 2025

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The document is an authorization form from the Wisconsin Department of Corrections for the use and disclosure of Protected Health Information (PHI). It outlines the necessary details for individuals or agencies to disclose PHI, including patient information, specific types of health information authorized for disclosure, and patient rights regarding their health information. The form also specifies conditions under which the authorization can be revoked and includes guidelines on who can sign the form on behalf of minors or incompetent adults.

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Click ‘Get Form’ to open the DOC-1163A in the editor.
Begin by filling in the 'Individual/Agency Being Authorized to Disclose PHI' section. Enter the name, telephone number, address, city, state, and zip code of the individual or agency.
Next, provide details about the 'Subject of Protected Health Information.' Fill in the patient's name, DOC number, address, housing unit, date of birth, and telephone number.
In the 'Recipient of Protected Health Information' section, enter the name and contact details of the individual or agency receiving the PHI.
Specify which types of protected health information you authorize for disclosure by checking appropriate boxes under 'Specific Protected Health Information Authorized for Use/Disclosure.'
Indicate any limitations on your authorization by describing specific medical conditions if applicable.
Complete the purpose for disclosure section by checking relevant categories such as ongoing health care or legal representation.
Finally, review your entries for accuracy before signing and dating the form at the bottom.

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Versions	Form popularity	Fillable & printable
2019	4.8 Satisfied (111 Votes)
2012	4.3 Satisfied (44 Votes)

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What is an example of a HIPAA authorization?

I hereby authorize use or disclosure of protected health information about me as described below. 4. I understand that the information used or disclosed may be subject to re-disclosure by the person or class of persons or facility receiving it, and would then no longer be protected by federal privacy regulations.

How to fill out authorization for use and disclosure of protected health information?

A bdocHub is defined as the acquisition, access, use, or disclosure of unsecured PHI that is not permitted by the HIPAA Privacy Rules and compromises the security or privacy of the PHI.

What is required for releasing protected health information?

A HIPAA release form is necessary whenever PHI is used or disclosed for a purpose not specifically required or permitted by the Privacy Rule.

What is included in the authorization for disclosure of PHI?

Specific and meaningful information, including a description, of the information that will be used or disclosed. The name (or other specific identification) of the person or class of persons authorized to make the requested use or disclosure.

What is an authorization for disclosure of protected information?

Under the Privacy Rule, a covered entity may use or disclose protected health information pursuant to a copy of a valid and signed Authorization, including a copy that is received by facsimile or electronically transmitted.