Voluntary and Informed Consent for Disclosure of Health Care Information

Document Number:  WKC-9488-E

Description:  This is a form to provide consent for release of medical information.

Comments:  This form 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 we are providing a PDF (WKC-9488) which you can print and complete by hand.

Content Contact:  Lynn Weinberger

Document Attachments:

WKC-9488-E (English Electronic Version - Word/54 KB)

WKC-9488 (English Print Version - pdf/145 KB)

WKC-9488-E-H (Hmong Electronic Version - Word/58 KB)

WKC-9488-H (Hmong Print Version - pdf/148 KB)

WKC-9488-E-S (Spanish Electronic Version - Word/57 KB)

WKC-9488-S (Spanish Print Version - pdf/95 KB)

*** If you need to access this form in an alternate format, please send an email to the Content Contact listed above.

*** 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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