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.
ETF will, consistent with the state’s Public Records Law, provide information regarding ETF’s affairs, except for individual personal information restricted by statute.
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.
If you are eligible to enroll in or change plans due to a qualified life change event, you may be asked to provide documents (employees to your employer, retirees to ETF) to confirm your eligibility.
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
Your WRS account information is confidential, and no one can receive information about or make changes to your account unless authorized. You can authorize another person to make changes to your account by submitting a financial power of attorney document to ETF.