JC-1631, 02/16 Notice of Medical Information and Birth/Adoptive Parent Identifying Info. Disclosure 24724748.427(6)(a), 48.432, 48.433 and 48.434, Wisconsin Statutes This form shall not be modified. It may be supplemented with additional material. Page 1 of 4 STATE OF WISCONSIN, CIRCUIT COURT, COUNTY IN THE INTEREST OF Name Date of Birth Notice of Medical Information and Birth/Adoptive Parent Identifying Information Disclosure Case No. The following information is being provided to the birth parent(s) pursuant to 24748.427(6)(a), Wis. Stats.: in person to birth mother birth father by mail to birth mother birth father 48.432 Access to medical information. (1) In this section: (a) "Adoptee" means a person who has been adopted in this state with the consent of his or her birth parent or parents before February 1, 1982. (ag) "Agency" means a county department or a licensed child welfare agency. http://docs.legis.wisconsin.gov/document/statutes/48.432(1)(am) (am) "Birth parent" means either: 1. The mother designated on the individual's or adoptee's original birth certificate. 2. One of the following: a. The adjudicated father. b. If there is no adjudicated father, the husband of the mother at the time the individual or adoptee is conceived or born, or when the parents intermarry under s. 767.803. (b) "Individual" means a person whose birth parent's rights have been terminated in this state at any time. (2) (a) The department, or agency contracted with under sub. (9), shall maintain all information obtained under s. 48.427 (6) (b) in a centralized birth record file. (b) Any birth parent whose rights to a child have been terminated in this state at any time, or who consented to the adoption of a child before February 1, 1982, may file with the department, or agency contracted with under sub. (9), any relevant medical or genetic information about the child or the child's birth parents, and the department or agency shall maintain the information in the centralized birth record file. (3) (a) The department, or agency contracted with under sub. (9), shall release the medical information under sub. (2) to any of the following persons upon request: 1. An individual or adoptee 18 years of age or older. 2. An adoptive parent of an adoptee. 3. The guardian or legal custodian of an individual or adoptee. 4. The offspring of an individual or adoptee if the requester is 18 years of age or older. 4m. The parent, guardian, or legal custodian of an offspring of a deceased individual or adoptee, if the offspring is under 18 years of age. 5. An agency or social worker assigned to provide services to the individual or adoptee or place the individual for adoption. (b) Before releasing the information under par. (a), the department, or agency contracted with under sub. (9), shall delete the name and address of the birth parent and the identity of any provider of health care to the individual or adoptee or to the birth parent. (c) The person making a request under this subsection shall pay a fee for the cost of locating, verifying, purging, summarizing, copying and mailing the medical or genetic information according to a fee schedule established by the department, or agency contracted with under sub. (9), based on ability to pay. The fee may not be more than $150 and may be waived by the department or agency. (4) (a) Whenever any person specified under sub. (3) wishes to obtain medical and genetic information about an individual whose birth parent's rights have been terminated in this state at any time, or whose birth parent consented to his or her adoption before February 1, 1982, or medical and genetic information about the birth parents of such an individual or adoptee, and the information is not on file with the department, or agency contracted with under sub. (9), the person may request that the department or agency conduct a search for the birth parents to obtain the information. (b) Upon receipt of a request under par. (a), the department, or agency contracted with under sub. (9), shall undertake a diligent search for the individual's or adoptee's parents. (c) Employees of the department and any agency conducting a search under this subsection may not inform any person other than the birth parents of the purpose of the search. American LegalNet, Inc. www.FormsWorkFlow.com JC-1631, 02/16 Notice of Medical Information and Birth/Adoptive Parent Identifying Info. Disclosure 24724748.427(6)(a), 48.432, 48.433 and 48.434, Wisconsin Statutes This form shall not be modified. It may be supplemented with additional material. Page 2 of 4 (d) The department, or agency contracted with under sub. (9), shall charge the requester a reasonable fee for the cost of the search. When the department or agency determines that the fee will exceed $100 for either birth parent, it shall notify the requester. No fee in excess of $100 per birth parent may be charged unless the requester, after receiving notification under this paragraph, has given consent to proceed with the search. (e) The department or agency conducting the search shall, upon locating a birth parent, notify him or her of the request and of the need for medical and genetic information. (f) The department, or agency contracted with under sub. (9), shall release to the requester any medical or genetic information provided by a birth parent under this subsection without disclosing the birth parent's identity or location. (g) If a birth parent is located but refuses to provide the information requested, the department, or agency contracted with under sub. (9), shall notify the requester, without disclosing the birth parent's identity or location, and the requester may petition the circuit court to order the birth parent to disclose the information. The court shall grant the motion for good cause shown. (7) (a) If the department or another agency that maintains records relating to the adoption of an adoptee or the termination of parental rights receives a report from a physician stating that a birth parent or another offspring of the birth parent has acquired or may have a genetically transferable disease, the department or agency shall notify the individual or adoptee of the existence of the disease, if he or she is 18 years of age or over, or notify the individual's or adoptee's guardian, custodian or adoptive parent if the individual or adoptee is under age 18. (b) If the department or agency receives a report from a physician that an individual or adoptee has acquired or may have a genetically transferable disease, the department or agency shall notify the individual's or adoptee's birth parent of the existence of the disease. (c) Notice under par. (a) or (b) shall be sent to the most recent address on file with the agency or the department. (8) Any person, including this state or any political subdivision of this state, who participates in good faith in any requirement of this section shall have immunity from any liability, civil or criminal, that results from his or her actions. In any proceeding, civil or criminal, the good faith of any person participating in the requirements of this section shall be presumed. (8m) The department, or agency contracted with under sub. (9), shall give priority to all of the following: (a) Reports filed by physicians under sub. (7). (b) A request or a court order for medical or genetic information under subs. (3) and (4) if it is accompanied by a statement from a physician certifying that a child has acquired or may have a genetically transferable disease. (c) Any reports and requests specified by the department by rule. (9) The department shall promulgate rules to implement this section and may contract with an agency to administer this section. 48.433 Access to identifying information about parents. (1) In this section: (a) "Agency" has the meaning given under s. 48.432 (1) (ag). (b) "Birth parent" has the meaning given under s. 48.432 (1) (am). (2) Any birth parent whose rights have been terminated in this state at any time, or who has consented to the adoption of his or her child in this state before February 1, 1982, may file with the department, or agency contracted with under