Restriction of Patient Health Information
Regarding Medicaid Autism Services
To assist transitioning to the waiver alternative, we will forward your
child’s name, your name, and address to your county agency. If you do not
want this information to be forwarded, please complete and send this form to
the address listed below by July 15, 2003. By sending this form, you are stating
that you DO NOT wish to have your child receive continued in-home autism
services that will be provided under the waiver alternative beginning in the
fall.
I hereby do not authorize disclosure of the named individual’s health
information to my county human services agency.
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__________________________ |
| Patient First |
Middle |
Last |
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Date of Birth |
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________________________________________ |
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__________________________ |
| Medicaid Card Number |
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Home Phone Number |
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____________________________________________________________________ |
| Signature of Parent or Legal
Guardian |
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Date |
Mail this form by July 15, 2003, to:
Alan White
Bureau of Program Integrity
P. O. Box 309
1 W. Wilson Street
Madison, WI 53701-0309
CH06026.CW Wisconsin.gov |
