2.31(a)(3) fashion: 164.508(c)(1)(i) The types of health care providers making the disclosure: 146.81(2)(c) ----- Specific name(s) or general designation(s) of the part 2 program(s), entity(ies) or individual(s) permitted to make disclosure: 2.31(a)(2) The name of the person authorized to make the disclosure. 252.15(3m)(b)3 Specifies the types of persons that are authorized to disclose information about the individual: 610.70(2)(a)3 The name or other specific identification of the person(s), or class of persons, authorized to make the requested use or disclosure: 164.508(c)(1)(ii) The individual, agency, or organization to which disclosure may be made: 146.81(2)(e) The name of the individual, agency or organization to which disclosure is to be made: 51.30(2) The name of the individual, agency or organization to which disclosure is to be made; or Entities with a treating provider relationship with the patient, or Entities without a treating provider relationship with the patient if Is a third-party payer, the name of the entity, or The entity is not listed above but facilitates the exchange of health information or is a research institution, the name(s) of the entity(ies), and The names of an individual participant(s), or The name(s) of an entity participant(s) that has a treating provider relationship with the patient whose information is The name of the person to whom the disclosure is authorized 252.15(3m)(b)4 The name of insurer and identifies by generic reference representatives of the insurer, to whom the information is authorized to be disclosed: 610.70(2)(a)5 The name or other specific identification of the person(s), or class of persons, to whom the CE may make the requested use or disclosure: 164.508(c)(1)(iii)
----- Each informed consent document shall include a statement that the patient has a right to inspect and receive a copy of the material to be disclosed: DHS 92.03(3)(d) ----- ----- ----- ----- ----- Any patient or patient representative may withdraw authorization for disclosure of any information at any time. If this occurs, an agency not included under s.51.30(4)(b) Stats., that requests release of information requiring informed consent shall be told only that s. 51.30, Stats., prohibit release of the information requested. DHS 92.03(3)(e) Authorization contains a statement that the consent is subject to revocation at any time except to the extent that the part 2 program or other lawful holder of patient identifying information that is permitted to make the disclosure has already acted in reliance on it. Acting in reliance includes the provision of treatment services in reliance on a valid consent to disclosure information to a third-party payer: 2.31(a)(6) ----- ----- A statement placing the individual on notice of the individual's right to revoke the authorization in writing, and either • The exceptions to the right to revoke and how to revoke [164.508(b)(5)], or • If the right to revoke is in the notice, a reference to the notice. 164.508(c)(2) (i) Note: An individual may revoke an authorization by providing a revocation in writing to the disclosing CE, except to the extent: 1) the disclosing CE has taken action in reliance on the authorization or 2) if the authorization was obtained as a condition of obtaining insurance coverage, other law provides the insurer with the right to contest a claim under the policy or the policy itself.