Release of Information - Hope Council on Alcohol & Other Drug Abuse, Inc.

Records & Consent

General Release of Information

Authorize Hope Council to release — or exchange — your records with a court, the Wisconsin DOT, an attorney, or another provider you name. This is the Wisconsin DHS release authorization (Form F-82009); you choose what is shared, with whom, and for how long.

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What this form does

This is the Wisconsin Department of Health Services Confidential Information Release Authorization (Form F-82009). Completing it authorizes Hope Council to release — or exchange — the records you check below with a person or organization you name, such as a court, the Wisconsin DOT, an attorney, or another provider. Signing is voluntary and refusal will not affect treatment, payment, enrollment, or benefits — except that clients seeking county funding must sign to be eligible. You may revoke it in writing at any time, except for information already released.

Confidential Information Release Authorization

Wisconsin DHS Form F-82009. Complete every required field; a separate release is used for each party you exchange records with.

"*" indicates required fields

Comments

This field is for validation purposes and should be left unchanged.

Full name*

Email*

Address

City, State, Zip

Client ID (Last 4 Digits of SSN)

Date of birth*

Agency authorized to release and/or receive information: Hope Council on Alcohol & Other Drug Abuse, Inc. · 6103 39th Ave., Kenosha, WI 53142 · (262) 658-8166 phone · (262) 658-8210 fax.

Information may be released to, and received from:

Name*

Organization*

Address*

City, State, Zip*

Records authorized for release

Assessment Summary
Progress
UA / Breathalyzer results
Progress Notes
Attendance
Participation in program
Treatment Plan
Collateral Information
Findings / Recommendations
Discharge Summary
Abstinence
Alcohol / Other Drug Test Results
Substance Abuse History
Psychiatric & psychological testing results
Other

Purpose or need for release

The purpose of this authorization is to support the coordination and delivery of services, facilitate communication with authorized individuals or organizations, and, when applicable, document participation, compliance with program requirements, or other authorized activities.

Understandings — please acknowledge

This authorization is voluntary. Refusal to sign will not affect treatment, payment, enrollment, or benefits eligibility — except that clients seeking county funding will not be eligible without signing.*

This authorization is voluntary. Refusal to sign will not affect treatment, payment, enrollment, or benefits eligibility — except that clients seeking county funding will not be eligible without signing.

Information released may be redisclosed by the recipient only if allowed by law, and redisclosed information may then be controlled by different laws.*

Information released may be redisclosed by the recipient only if allowed by law, and redisclosed information may then be controlled by different laws.

I may revoke this authorization in writing at any time, except for information already released. The written revocation must be given to the releasing agency named above.*

I may revoke this authorization in writing at any time, except for information already released. The written revocation must be given to the releasing agency named above.

Understandings — please acknowledge*

This authorization expires 16 months after the date I sign

By signing this document, I authorize the mutual disclosure, exchange, and receipt of the specific information identified in this authorization between Hope Council on Alcohol & Other Drug Abuse, Inc. and the individual(s), organization(s), or agency(ies) named in this release. This authorization permits both parties to disclose information to and receive information from one another for the purposes described above.

Signature

Signature — record subject*

Date

Signature — other person legally authorized to consent

Title or relationship to record subject

Date signed

Common Questions

Do I have to sign this?dooley2026-07-14T19:01:12-05:00

Records & Consent

General Release of Information

What this form does

Confidential Information Release Authorization

Common Questions

Do I have to sign this?

Can I change my mind later?

How long does the authorization last?

Can the recipient share my information further?

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