Wilder Release of Information (for Web)

Client Name*

First NameMiddle InitialLast Name

Date of Birth*

Date

Client # (if known)

I hereby authorize Amherst H. Wilder Foundation to:*

Exchange withObtain fromRelease to

Facility/Individual Name *
Address Street Address   Address Line 2   City   State   Zip
Phone Fax

Wilder releases one year of records unless specific date range is selected:

For a specific date range

For this specific time period: Start Date: Date* End Date: Date*

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

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 Encryption?*

YesNo - Selecting this option means the information being sent could be visible to others and is not secure

Email

example@example.com

Fax Number

Please enter a valid phone 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*

Person Requesting Records*

First NameLast Name

Indicate Relationship to Client*

ClientParentIf you are not the patient/parent, state your relationship/authority to submit request

Requester Email*

example@example.com

Requester Phone Number*

Please enter a valid phone number.

Today's Date*

Date

Consent for the Release of Records Request