Outdated or Unsupported Browser Detected
DWD's website uses the latest technology. This makes our site faster and easier to use across all devices. Unfortunatley, your browser is out of date and is not supported. An update is not required, but it is strongly recommended to improve your browsing experience. To update Internet Explorer to Microsoft Edge visit their website.
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/168 KB)
WKC-9488-E-H (Hmong Electronic Version - Word/59 KB)
WKC-9488-E-H (Hmong Electronic Version - pdf/207 KB)
WKC-9488-E-S (Spanish Electronic Version - Word/61 KB)
WKC-9488-E-S (Spanish Electronic Version - pdf/174 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
Sign up for DWD news and updates
A proud partner of the 
network