Request for the Release of Records (Wilder.org)

Client Name*

First NameMiddle NameLast Name

Date of Birth*

Date

Client # (if known)

Facility/Individual Name *
Address (Street | Apt/Bldg | City, State Zip)
Phone Number:* Fax:

I hereby authorize Amherst H. Wilder Foundation to:*

Exchange withObtain fromRelease to

Wilder only releases the last year of records, unless a specific date range is indicated below:

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:

Wilder will release your records containing mental health, substance use or other health information including the following below:*

Please select an option below to authorize the release of records that include information about Substance Use Disorder Treatment:*

Yes, I give permission to share my records about Substance Use Disorder treatment.No, do not share records about Substance Use Disorder treatment.

If client is under 18, only the minor may consent to the release of the following information:

HIV/AIDS StatusSexually Transmitted InfectionsSubstance Abuse

Reason for Release*

Release Method*

Email

example@example.com

Email Encryption?*

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.

This release will expire in one year unless indicated below:

Date

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 of Client or Guardian*

Printed Name*

First NameLast Name

Relationship to the Client (if applicable):

Today's Date*

Date

Request for Release of Records