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Requests for information about drug and alcohol patient
records will need to include a release of confidential
information form that meets the requirements of federal
regulations on Confidentiality of Alcohol and Drug Abuse
Patient Records found in Chapter 42, Part 2, of the Code of
Federal Regulations, or a proper court order.
Closed treatment agencies usually maintain their own
closed client files. DBHR maintains some closed client
files from closed agencies.
- To find out who the Patient Record Custodian is for
closed agencies, contact:
Jennifer Fine at 360-725-3703, or e-mail
finejk@dshs.wa.gov, or Renee Anderson at 360-725-3728
or e-mail
anderrd@dshs.wa.gov.
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Authorization DSHS 17-063
Use this form when you want DBHR/DSHS to release of your
confidential patient/client information to another party. If
you believe that DBHR has archived your closed
client/patient file due to a treatment agency closing, call
before sending the form. Most treatment agencies appoint a
records custodian to maintain their records when closing, or
they maintain their own records.
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Release of
Confidential Information Use this form to request a
certified treatment agency to send your records to another
party. This is a Sample fill-in form (HIPAA & 42 CFR Part 2
compliant). Do not use this form for records held by DSHS.
The requirement that the patient's revocation be in writing
was removed from this form per the recommendation of the
Legal Action Center
www.lac.org.
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