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Document Number: WKC-9488-E
Description: This is a form to provide consent for release of medical information.
Comments: This form is an electronictemplate that can be filled out on your computer. You can also print and complete this form by hand.
Content Contact: Lynn Weinberger
Document Attachments:
WKC-9488-E (English Electronic Version - Word/57 KB)
WKC-9488-E (English Electronic Version - pdf/145 KB)
WKC-9488-E-H (Hmong Electronic Version - Word/62 KB)
WKC-9488-E-H (Hmong Electronic Version - pdf/152 KB)
WKC-9488-E-S (Spanish Electronic Version - Word/61 KB)
WKC-9488-E-S (Spanish Electronic Version - pdf/152 KB)
Note: If you need this form in an alternate format, please send a message to the Content Contact listed above.
DWD Contact Information
201 E. Washington Ave
P.O. Box 7946
Madison, WI 53707
(608) 266-3131
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