Upon approval of this application I hereby authorize payroll deductions from my earnings. I hereby authorize any and all physicians, hospitals, clinics, etc. to release to the Wisconsin Department of Employee Trust Funds or the ICI Program Administrator information from my health record. I understand that the specific type of information to be released includes any and all medical and/or treatment records, and may include records pertaining to alcohol abuse, drug abuse, records with reference to child abuse, developmental disabilities, mental illness, HTLV-III (AIDS) testing and results, and/or treatment records. This release is being made for the purpose of applying for insurance.
I understand that Wis. Stat. § 943.395, provides criminal penalties for knowingly making false or fraudulent claims and hereby certify that, to the best of my knowledge and belief, the information I have provided while applying for income continuation insurance is true, correct and complete.