An informed consent for disclosure of information to an individual, agency, or organization other than the consumer or a designated representative must be in writing and must contain all of the following:

1. (1) The name of the person or organization to which the disclosure is to be made.
2. (2) The name of the consumer.
3. (4) The specific type of information to be disclosed.
4. (5) The time period during which the consent is effective.
5. (6) The date on which the consent is signed.

6. (7) The signature of the consumer or person legally authorized to give consent for the consumer.

   Note: A form for providing informed consent for disclosure of information may be accessed online at https://dwd.wisconsin.gov/dwd/forms/dvr/dvr-199-e.htm.

History

History: Cr. Register, June, 1976, No. 246, eff. 7-1-76; renum. from DVR 1.05, Register, April, 1982, No. 316, eff. 5-1-82; CR 22-008: am. (intro.), (1), (2), r. (3), am. (4) to (7) Register June 2022 No. 798, eff. 7-1-22.