Structure
The Wisconsin Doc 1163 form serves as a critical tool for individuals seeking to authorize the disclosure of non-health confidential information. It is specifically designed to comply with various state statutes and federal regulations, ensuring that sensitive data is handled appropriately. This form is not intended for the release of protected health information; for such purposes, a different form, DOC-1163A, must be utilized. The Doc 1163 form allows individuals to specify who is authorized to release information, detailing both the subject of the records and the specific information that may be disclosed. This includes categories such as education and employment records, enabling a comprehensive understanding of an individual’s background. The form also accommodates two-way releases, facilitating the exchange of information between parties. Importantly, it highlights the rights of the individual regarding the authorization process, emphasizing that signing the form is voluntary and that the individual has the right to inspect and copy their records. The authorization can have a defined expiration, either based on a specific date or an event, ensuring that the consent remains relevant and controlled. Overall, the Doc 1163 form is essential for managing the delicate balance between confidentiality and the need for information sharing in various contexts, including legal and educational settings.
Form Example
DEPARTMENT OF CORRECTIONS |
WISCONSIN |
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Division of Management Services |
Wisconsin Statutes - Sections 19.35, 19.36 |
& 118.125 |
Federal Regulations 42 CFR Part 2 & 45 CFR Parts |
160 & 164 |
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AUTHORIZATION FOR DISCLOSURE OF
CONFIDENTIAL INFORMATION
NOTICE: DO NOT USE TO AUTHORIZE DISCLOSURE OF PROTECTED HEALTH INFORMATION. USE FORM
INDIVIDUAL/AGENCY BEING AUTHORIZED TO RELEASE INFORMATION/RECORD(S)
NAME OF INDIVIDUAL / AGENCY |
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TELEPHONE NUMBER |
FAX NUMBER |
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ADDRESS |
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CITY |
STATE |
ZIP CODE |
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SUBJECT OF INFORMATION/RECORD(S) |
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NAME
ADDRESS
IDENTIFYING/DOC NUMBER |
DATE OF BIRTH |
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CITY |
STATE |
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ZIP CODE |
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INFORMATION/RECORD(S) MAY BE RELEASED TO
NAME OF INDIVIDUAL / AGENCY |
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TELEPHONE NUMBER |
FAX NUMBER |
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ADDRESS |
CITY |
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STATE |
ZIP CODE |
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SPECIFIC INFORMATION AUTHORIZED FOR DISCLOSURE
INSTRUCTIONS: Check All That Apply
Institution Social Service File (Use
Legal
Division of Community Corrections File (Use
I understand that the information I am authorizing for release may contain Personally Identifiable Information (PII) such as complete date of birth, driver’s license number, state ID number or social security number.
Check the category(ies) and
EDUCATION
Identify Time Period Of Records:
Regular education information/records (including attendance records)
High School Transcript
Other:
SPED information/record(s) e.g. IEP, MMPI,
GED or HSED Scores
High school credits |
Disciplinary Actions |
Vocational/technical school or college transcript
Purpose: 
To assist in educational/vocational planning
Purpose: 
To complete PSI
Other:
EMPLOYMENT
Identify Time Period Of Records: |
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Period(s) of employment |
Job performance evaluation(s) |
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Purpose: |
To assist in career planning |
Other |
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Job attendance
Job duties & title
CONTINUED
Purpose: |
To complete PSI |
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OTHER
Identify Time Period Of Records:
Type(s) or information/record(s):
Purpose:
YOUR RIGHTS WITH RESPECT TO THIS AUTHORIZATION
Signing of Authorization - I am under no legal obligation to sign this authorization. If I do, I have a right to receive a copy.
AODA Information - My educational information/record(s) may contain alcohol and other drug abuse information. If so, I must sign
Right to Inspect and/or Copy Education Information/Records - I have the right to inspect and copy my educational records as permitted under s. 118.125 Wis. Stats. I may be charged a reasonable fee for copies.
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AUTHORIZATION SIGNATURE |
INITIAL ONE ONLY (Required) |
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Authorization expires as of: |
, (Date) |
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Authorization expires: |
, month(s) from the date I sign this authorization. |
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Authorization expires after the following action takes place:
Authorization expires upon substantial change in criminal justice system status. (e.g., released from prison.)
If no date/event is entered, this Authorization expires one year from the date of signing.
I have read or had read to me the contents of this authorization. I have had an opportunity to discuss and ask questions. By signing this authorization, I am confirming that it accurately reflects my wishes regarding disclosure of confidential information.
SIGNATURE OF INDIVIDUAL WHO IS SUBJECT OF RECORD |
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DATE SIGNED |
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SIGNATURE OF OTHER PERSON LEGALLY AUTHORIZED |
TITLE OR RELATIONSHIP TO INDIVIDUAL WHO IS |
DATE SIGNED |
TO CONSENT TO DISCLOSURE (If Applicable) |
SUBJECT OF RECORD |
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FAX OR PHOTOCOPY MAY BE TREATED AS ORIGINAL
DISTRIBUTION: Original- Individual/Agency authorized to release Information/Record(s);
Official
Document Specs
| Fact Name | Description |
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| Form Title | Authorization for Disclosure of Non-Health Confidential Information |
| Governing Laws | Wisconsin Statutes - Sections 19.35, 19.36 & 118.125 |
| Federal Regulations | 42 CFR Part 2 & 45 CFR Parts 160 & 164 govern the privacy of substance use disorder patient records. |
| Form Revision Date | The form was last revised in March 2015. |
| Purpose of the Form | This form is used to authorize the release of non-health confidential information. |
| Exclusions | It is important to note that this form should not be used for disclosing protected health information. |
| Two-way Release | Individuals can authorize a two-way exchange of information between agencies. |
| Right to Inspect | Individuals have the right to inspect and copy their educational records as allowed under s. 118.125 Wis. Stats. |
| Expiration of Authorization | The authorization can expire on a specified date, after a certain number of months, or upon a significant change in criminal justice status. |
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