• Authorization for the Release of Records Request

    Authorization for the Release of Records Request

    (wilder.org/myhealth)
  • Client Information

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  • 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)
  • Facility/Individual Name *      
    Address                 
    Phone  Fax        
       

  • Information to be Released

  • For this specific time period: Start Date:   Pick a Date*      End Date:   Pick a Date*   

  • 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

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  • 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. Federal confidentiality regulations (42 CFR, part 2) prohibit re-disclosure of information from alcohol and drug abuse treatment 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.
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  • Amherst H. Wilder Foundation

    wilder.org/myhealth
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