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Authorization to Release WIC Information

2. 

3. Authorization to Release WIC Information

5. Household ID#:

7. Name of WIC Client:*

8. Date of Birth:*
   Date of Birth:

10. Name of WIC Client:

11. Date of Birth:
    Date of Birth:

13. Name of WIC Client:

14. Date of Birth:
    Date of Birth:

16. How will we use this data:
    The Public Health Programs listed below will use this data: 1.) To determine whether I am eligible to participate in those programs; and/or 2.) To provide services under those programs if I am eligible and wish to participate. 3.) If referred, my medical provider will use the data to provide health care to me.

    The Public Health Programs listed below will use this data: 1.) To determine whether I am eligible to participate in those programs; and/or 2.) To provide services under those programs if I am eligible and wish to participate. 3.) If referred, my medical provider will use the data to provide health care to me.

18. Consent to Release and Exchange Information:
    I give my consent to the Chisago County WIC (Women & Children) Program to release and exchange information about myself and/or my minor child(ren) with:

    I give my consent to the Chisago County WIC (Women & Children) Program to release and exchange information about myself and/or my minor child(ren) with:

20. Select authorized program(s), medical provider(s) I consent to release and exchange of information:*

    1. Family Home Visiting
    2. CT&C (Child & Teem Checkup)
    3. Follow Along
    4. Immunization
    5. Financial
    6. My Medical Provider(s) - see information below
    7. Other Provider/Organization - see information below
    8. I do NOT give my consent to release and exchange information about myself and/or my minor child(ren)

22. If 'My Medical Provider(s)' is selected above, please complete the following:

24. Physician/Clinic:

25. Clinic Location:

27. Phone:

28. Fax:

30. If 'Other Provider/Organization' is selected above, please enter provider/organization information:

32. Information to be Released: (Please select/authorize information you wish to share)*

    1. Only Limited Information - Information is detailed below
    2. All information about myself that I have provided to the WIC Program and all measurements and assessments about me made by the WIC Program.
    3. Only my participation in the WIC Program and my current contact information.

34. If 'Only limited information' is selected above, please detail what information you authorize us to release and exchange:

36. How will your privacy be protected:
    WIC Program data about you is private and is protected by federal and state privacy law. The Chisago County WIC Program will not release identifying data to any person without your permission.

    WIC Program data about you is private and is protected by federal and state privacy law. The Chisago County WIC Program will not release identifying data to any person without your permission.

38. Unless otherwise authorized or required by law, staff of the Public Health Programs will have access to the data to the extent needed to perform their job duties for the programs.

40. Whether I need to sign:
    I understand that I do not have to agree to the release of information described in this document. I also understand that refusing to sign this authorization will not affect my eligibility or participation in the WIC Program or any other Public Health Program, will not affect the current or future care I receive from any health care provider, and will not cause any penalty or loss of benefits to which I am otherwise eligible.

    I understand that I do not have to agree to the release of information described in this document. I also understand that refusing to sign this authorization will not affect my eligibility or participation in the WIC Program or any other Public Health Program, will not affect the current or future care I receive from any health care provider, and will not cause any penalty or loss of benefits to which I am otherwise eligible.

42. If I do not sign the authorization it may be more difficult and time consuming for Chisago County to coordinate public health services for me. Chisago County may need to ask me the same health information questions or take the same measurements/health tests more than once.

44. Cancelling my permission:
    I may cancel my permission at any time. In order to cancel my permission, I need to provide notice in writing to the Chisago County WIC Program and include my name, date of birth and signature.

    I may cancel my permission at any time. In order to cancel my permission, I need to provide notice in writing to the Chisago County WIC Program and include my name, date of birth and signature.

46. Preferred method(s) to be contacted by county program staff, please check:*

    1. Phone
    2. Text

47. Phone number:

48. Cell number:

49. Best time to contact:

51. This authorization expires one (1) year from the date of my signature, unless it is revoked at anytime by me.

53. I agree and consent to providing a digital signature.

55. Signature of Client / Parent / Guardian:*

56. Date Signed:*
    Date Signed:

58. Relationship to Minor Client:

Leave This Blank:


59. 1. Receive an email copy of this form.
60. Email address

    This field is not part of the form submission.

61. Submit

* indicates a required field