Get Wi Wps 21339 2016-2025

Filling out the WI WPS 21339 form online is an important step in authorizing the release of your protected health information. This guide provides clear instructions and helpful tips to ensure that you complete the form accurately and efficiently.

Follow the steps to successfully complete the WI WPS 21339 form online.

1. Click ‘Get Form’ button to access the form and open it for editing.
2. In Part A, enter the member's information, including their last name, first name, address, daytime phone number, city, cell phone number, subscriber number, middle initial, date of birth, state, zip code, and group number.
3. Navigate to Part B and list the individuals or companies that will receive the information. Check each applicable box and provide the required names.
4. In Part C, specify what information you are allowing to be released. Choose either 'All of my information' or specify limited information by checking the appropriate boxes.
5. If applicable, indicate any sensitive information that can be released by checking the boxes related to sensitive topics.
6. In Part D, state the purpose of this approval by selecting the relevant option.
7. Provide the expiration date of your approval in Part E by choosing one of the options provided.
8. In Part F, choose the format in which you authorize the transmission of your information: paper copies, fax, digital copies, or email. Provide the necessary contact information.
9. Review the form for accuracy. In Part G, read the terms and conditions, then sign and date the form to confirm your approval.
10. Finally, save your changes and download or print the completed form. You may also share it as needed before mailing or faxing it to WPS Privacy Office.

Complete your WI WPS 21339 form online today for a smooth and efficient process.