Wisconsin Department of Workforce Development

Medical Release Authorization

Document Number: ERD-4972
Description: This form is used to give permission for the Division to obtain medical information.
Division: Equal Rights
Comments: This authorization is to be used to assist in the investigation of a complaint filed with the Equal Rights Division of the Department of Workforce Development.
Content Contact: Equal Rights Information

This version is an electronic Microsoft Word template that can be filled out on your computer (if you have Microsoft Word).  If you do not have Microsoft Word, you should use the ERD-4972 version that is not fill enabled and should be printed and completed by hand.
MS Word Document Attachment:  ERD-4972-E

This version is not fill enabled. It can be printed and completed by hand.  If you have Microsoft Word and want a form field fill-enabled form that can be filled out on your computer you may use the ERD-4972-E
PDF Document Attachment:  ERD-4972
  

***Should you require the necessary software to view the above attachment, please go to the DWD Viewers Download Page. Links to each specific vendor's site have been provided for you. Thank you.

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