Wilder.org - Request for the Release of Information

Consent for the Release of Records

Wilder Clinic
Client Name*

First NameMiddle NameLast Name
Date of Birth*

MonthDayYear
Date
Client # (if known)
Parties Sharing Information
Amherst H. Wilder Foundation Wilder Programs

451 Lexington Parkway N St Paul, MN 55104 651-280-2101 (P) | 651-280-3995 (F)
Release toObtain from
Facility/Individual Name *
Relationship to client*
Address (Street | Apt/Bldg | City, State Zip)
   Phone Number:*   Fax:
Information to be Released
Release only the records from the most recent year.Release records from all datesRelease records for a specific date range
For this specific time period: StartDate:* . End Date:
Entire RecordAssessments/EvaluationsTreatment PlansClosing/Discharge SummariesCourt/Commitment RecordsMedicationsSchool Communication& RecordsUrinalysis/Blood Alcohol ResultsVisit/Progress NotesNon-Wilder Third Party Service RecordsOther
Yes, I give permission to share my records about Substance Use Disorder treatment.No, do not share records about Substance Use Disorder treatment.
HIV/AIDS StatusSexually Transmitted InfectionsSubstance Abuse
Notice Prohibiting Re-disclosure of Alcohol or Drug Abuse Information

This record which has been disclosed to you is protected by federal confidentiality rules (42 CFR part 2). The federal rules prohibit you from making any further disclosure of this record unless further disclosure is expressly permitted by the written consent of the individual whose information is being disclosed in this record or is otherwise permitted by 42 CFR, Part 2. A general authorization for the release of medical or other information is NOT sufficient for this purpose. The federal rules restrict any use of the information to investigate or prosecute with regard to a crime any patient with a substance use disorder.
Reasons, Methods & Expiration of Release
Treatment/Continued Care/Coordination of ServicesSchool Evaluation/Special Ed NeedsInsurance/PaymentDisability BenefitsLegalOther
AllEmailFaxPostal MailVerbal
Email
example@example.com
YesNo - Selecting this option means the information being sent could be visible to others and is not secure
Fax Number
Please enter a valid fax number.Format: (000) 000-0000.
This release will expire in one year unless indicated below:
Date

MonthDayYear
Date
I Understand That by Signing This Authorization
- My health information is protected by federal and state privacy laws and regulations. Disclosure/release is allowed only with my authorization except in limited circumstances as described in the Wilder Foundation Notice of Privacy Practices.
- I have a right to inspect and receive a copy of my records that may be released to others, as provided under applicable laws.
- I may revoke this authorization by notifying in writing the Wilder Foundation Medical Records team. This would not apply to actions already taken.
- Once Wilder releases records, Wilder cannot prevent them from being shared with a third party. At that point, the records may no longer be protected by state and federal privacy laws. For substance use disorder records, 42 CFR part 2 prohibits unauthorized use or disclosure of these records.
- For disclosures other than for treatment, payment and health care operations purposes, treatment may not be conditioned on my agreement to sign this authorization.
- A photocopy of this form is as valid as the original and I will receive a copy of this signed form upon request.
- This release will expire one year from the date the form is signed unless otherwise specified.
Signature
Signature of Client or Guardian*

Clear
Printed Name*

First NameLast Name
Relationship to the Client (if applicable):
Today's Date*

MonthDayYear
Date
Should be Empty:

Consent for the Release of Records

Parties Sharing Information

Amherst H. Wilder Foundation Wilder Programs

Information to be Released

Notice Prohibiting Re-disclosure of Alcohol or Drug Abuse Information

Reasons, Methods & Expiration of Release

I Understand That by Signing This Authorization

Signature