SeniorCare Privacy Information and Forms

Wisconsin’s Department of Health Services (DHS) SeniorCare program is committed to protecting the privacy of your medical information. Your privacy is already protected under Wisconsin law. In addition, federal law requires health plans, like SeniorCare, to protect your medical information and to let you know how your medical information may be used and released to others.  The Notice of Privacy Practices explains how medical information about you may be used and disclosed and how you can get access to this information.

Privacy Notice and Forms

  • SeniorCare Notice of Privacy Practices — P-13041
  • Wisconsin SeniorCare HIPAA Privacy Authorization for Use or Disclosure — F-13161 (PDF, 109 KB)
  • Wisconsin SeniorCare HIPAA Privacy Access Request — F-13162 (PDF, 100 KB)
  • Wisconsin SeniorCare HIPAA Privacy Accounting Request — F-13163 (PDF, 92 KB)
  • Wisconsin SeniorCare HIPAA Privacy Alternate Communication Request — F-13164 (PDF, 96 KB)
  • Wisconsin SeniorCare HIPAA Privacy Amendment Request — F-13165 (PDF, 88 KB)
  • Wisconsin SeniorCare HIPAA Privacy Complaint — F-13166 (PDF, 92 KB)
  • Wisconsin SeniorCare HIPAA Privacy Revocation of Authorization — F-13167 (PDF, 96 KB)
  • Wisconsin SeniorCare HIPAA Privacy Restriction Request — F-13168 (PDF, 88 KB)
  • SeniorCare Authorization of Representative — F-10080 (PDF, 72 KB)

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Last Revised: September 28, 2016