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The Wisconsin Doc 1163 form is an Authorization for Disclosure of Non-Health Confidential Information. This document allows individuals to authorize the release of specific information related to their educational, employment, or other records, while ensuring that protected health information remains confidential. If you need to fill out this form, click the button below to get started.

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The Wisconsin DOC-1163 form serves a crucial role in managing the disclosure of non-health confidential information, particularly within the context of the state's correctional system. This form is designed for individuals or agencies seeking to authorize the release of specific records, which may include educational, employment, or other personal information. It is essential to note that the DOC-1163 is not intended for the disclosure of protected health information; for that purpose, a different form, DOC-1163A, must be utilized. The form outlines the necessary details, including the names and contact information of both the individual authorizing the release and the recipient agency or individual. Users must specify the types of records they wish to disclose, along with the time periods for which these records are relevant. Additionally, the form includes important rights regarding the authorization process, such as the right to inspect and copy educational records, as well as the implications of re-disclosure. By signing the DOC-1163, individuals confirm their understanding of the process and their consent to share their confidential information, ensuring that all parties involved are clear on the scope and purpose of the disclosure.

Listed Questions and Answers

What is the purpose of the Wisconsin Doc 1163 form?
The Wisconsin Doc 1163 form is used to authorize the disclosure of non-health confidential information. It allows individuals to give permission for specific records or information to be shared with designated individuals or agencies. This can include educational and employment records, among others.
Who can use the Doc 1163 form?
The form can be used by individuals who need to authorize the release of their confidential information. This includes those involved in the criminal justice system or those seeking assistance with educational or vocational planning.
What types of information can be disclosed using this form?
The form allows for the disclosure of various types of information, such as:
- Educational records, including transcripts and attendance records
- Employment records, such as job performance evaluations
- Social service files
- Legal records from the Division of Community Corrections
What should I do if I want to include health information?
If you need to authorize the disclosure of health information, you should use the DOC-1163A form instead. The Doc 1163 form specifically excludes protected health information.
How long does the authorization last?
The authorization on the Doc 1163 form can last for a specified time period, which you can indicate on the form. If no specific date or event is mentioned, the authorization will expire one year from the date you sign it.
What rights do I have regarding my information?
You have several rights concerning your information, including:
- The right to inspect and copy your educational records
- The right to receive a copy of the authorization once signed
- The right to refuse to sign the authorization without facing legal consequences
What happens if I change my mind after signing the form?
If you decide to revoke your authorization after signing, you must do so in writing. This will prevent any further disclosure of your information as specified in the authorization.

Key takeaways

When using the Wisconsin DOC-1163 form, there are several important aspects to keep in mind:

Purpose of the Form: The DOC-1163 form is specifically designed for the authorization of non-health confidential information. It cannot be used to disclose protected health information, for which a different form (DOC-1163A) is required.
Information Categories: Users must specify which categories of information they are authorizing for release. This includes education, employment, and other relevant records. It is essential to check all applicable boxes to ensure clarity.
Rights of the Individual: Individuals have the right to refuse to sign the authorization. If they do sign, they are entitled to a copy of the authorization. Additionally, they can inspect and copy their educational records as permitted by law.
Expiration of Authorization: The authorization can have a specific expiration date or event noted. If not specified, it will automatically expire one year from the date of signing. This is crucial for maintaining control over personal information.

Document Overview

Fact Name	Description
Governing Laws	This form is governed by Wisconsin Statutes Sections 19.35, 19.36, and 118.125.
Federal Regulations	It complies with Federal Regulations 42 CFR Part 2 and 45 CFR Parts 160 and 164.
Form Purpose	The DOC-1163 is used to authorize the disclosure of non-health confidential information.
Health Information	This form should not be used for protected health information. For that, use DOC-1163A.
Two-way Release	The form allows for a two-way release of information between the authorized parties.
Education Records	It can authorize the release of various educational records, including transcripts and disciplinary actions.
Employment Records	Employment information such as job performance evaluations can also be disclosed using this form.
Rights of Individuals	Individuals have the right to inspect and copy their educational records as per Wisconsin law.
Expiration of Authorization	The authorization expires one year from the signing date unless otherwise specified.

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Misconceptions

Understanding the Wisconsin Doc 1163 form can be challenging, and several misconceptions may lead to confusion. Here are eight common misunderstandings, clarified for better comprehension:

It can be used for health information disclosure. The Wisconsin Doc 1163 form is specifically designed for non-health confidential information. For health-related disclosures, the DOC-1163A form must be used instead.
All types of information can be released with this form. This form allows for the release of specific categories of information, such as educational and employment records, but not health information.
Signing the form is mandatory. Individuals are not legally obligated to sign the authorization. Signing is entirely voluntary, and individuals have the right to receive a copy of the signed form.
Once signed, the authorization lasts indefinitely. The authorization has a defined expiration. It can expire on a specific date, after a certain number of months, or upon a significant change in the individual’s criminal justice status.
Re-disclosure of information is always permitted. If the information is shared with an entity that is covered by federal or state laws prohibiting re-disclosure, the recipient cannot share it further without additional consent.
Individuals cannot inspect their own records. Individuals have the right to inspect and copy their educational records, as allowed under Wisconsin law. There may be a fee for copies, but access is guaranteed.
All educational records are treated the same. Certain records, especially those containing information about alcohol and drug abuse, require the use of the DOC-1163A form for disclosure. This ensures that sensitive information is handled appropriately.
Faxed or photocopied forms are not valid. A fax or photocopy of the signed authorization may be treated as an original, ensuring that the process remains efficient and accessible.

By understanding these misconceptions, individuals can navigate the complexities of the Wisconsin Doc 1163 form more effectively, ensuring that their rights and privacy are respected.

Form Sample

DEPARTMENT OF CORRECTIONS	WISCONSIN
Division of Management Services	Wisconsin Statutes - Sections 19.35, 19.36	& 118.125
DOC-1163 (Rev. 3/2015)	Federal Regulations 42 CFR Part 2 & 45 CFR Parts	160 & 164

AUTHORIZATION FOR DISCLOSURE OF NON-HEALTH

CONFIDENTIAL INFORMATION

NOTICE: DO NOT USE TO AUTHORIZE DISCLOSURE OF PROTECTED HEALTH INFORMATION. USE FORM DOC-1163A

INDIVIDUAL/AGENCY BEING AUTHORIZED TO RELEASE INFORMATION/RECORD(S)

NAME OF INDIVIDUAL / AGENCY			TELEPHONE NUMBER		FAX NUMBER

ADDRESS		CITY		STATE	ZIP CODE

	SUBJECT OF INFORMATION/RECORD(S)

NAME

ADDRESS

IDENTIFYING/DOC NUMBER	DATE OF BIRTH
CITY	STATE	ZIP CODE

INFORMATION/RECORD(S) MAY BE RELEASED TO

NAME OF INDIVIDUAL / AGENCY		TELEPHONE NUMBER		FAX NUMBER

ADDRESS	CITY		STATE	ZIP CODE

SPECIFIC INFORMATION AUTHORIZED FOR DISCLOSURE

INSTRUCTIONS: Check All That Apply

Institution Social Service File (Use DOC-1163A for disclosure of information relating to therapy/counseling provided by a social worker or any other health information.)

Legal

Division of Community Corrections File (Use DOC-1163A for disclosure of any health information.)

Two-way Release By checking this box I authorize the individual/agency named in this authorization, to RELEASE TO EACH OTHER, only the information/records listed for release on this form in the category(ies) below. I authorize this exchange of information on an ongoing basis for the duration of this authorization.

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 sub-categories of information authorized for release.

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, M-Team, etc.

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:
Period(s) of employment		Job performance evaluation(s)
Purpose:	To assist in career planning		Other

Job attendance

Job duties & title

CONTINUED

DOC-1163 CONTINUED

Purpose:	To complete PSI

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 DOC-1163A or that information will be redacted before the education information/record(s) are released.

Re-disclosure of Education Information/Record(s) - If I authorize release of education information/record(s) to an individual or agency covered by federal or state laws that prohibit re-disclosure, the recipient cannot re-disclose the information/records without a signed information release from me, a court order or other specific authorization under the law . However, if I consent to release education information/record(s) to an individual/agency not covered by federal or state laws that prohibit re-disclosure, my private information/record(s) may not remain confidential.

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.

		AUTHORIZATION SIGNATURE
INITIAL ONE ONLY (Required)
	Authorization expires as of:	, (Date)

	Authorization expires:	, month(s) from the date I sign this authorization.

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		DATE SIGNED

SIGNATURE OF OTHER PERSON LEGALLY AUTHORIZED	TITLE OR RELATIONSHIP TO INDIVIDUAL WHO IS	DATE SIGNED
TO CONSENT TO DISCLOSURE (If Applicable)	SUBJECT OF RECORD

FAX OR PHOTOCOPY MAY BE TREATED AS ORIGINAL

DISTRIBUTION: Original- Individual/Agency authorized to release Information/Record(s); Copy-Offender/Other Person Signing Release;

Official Record-Appropriate Offender Education/Legal File, Right Side/Social Service File, Left Side