This form gives ETF and entities that perform contracted services for ETF permission to release your designated medical information to a person or entity specified by you.
Level 4 self-injectables and specialty medications are available through specific pharmacies for non-Medicare members while members on Medicare have some additional pharmacy options.
Program Option
Local Annuitant Health Program (LAHP)
Local Deductible Health Plan (PO14) & Supplemental Benefits
Local Deductible Health Plan with Uniform Dental (PO4) & Supplemental Benefits
Local Health Plan (PO16) & Supplemental Benefits
Local Health Plan with Uniform Dental (PO6) & Supplemental Benefits
Local High Deductible Health Plan (PO17) & Supplemental Benefits
Local High Deductible Health Plan with Uniform Dental (PO7) & Supplemental Benefits
Local Traditional Health Plan (PO12) & Supplemental Benefits
Local Traditional Health Plan with Uniform Dental (PO2) & Supplemental Benefits
State Employee and Retiree Health Plan & Supplemental Benefits
The Public Records notice for records pertaining to the Employee Trust Funds board, Teachers Retirement Board, Wisconsin Retirement Board, Group Insurance Board and Deferred Compensation Board.
ET-7406
Form
Active Employee /
Retiree /
Other Benefit Recipient
Wisconsin law allows ETF to release personal information to a third party if the member has first provided ETF with a valid written authorization. Use this form to authorize the release of non-medical information.
