WCCS-73000-16 (7-11) 2p
Chemical Health Services
Data Practices Rights Advisory
Under the Minnesota Government Data Practices Act, Minnesota Statutes Chapter 13,
Washington County is required to inform you of your rights as they pertain to the private and
confidential information collected from you and that is about you. Private data is that information that
is available to you but not to the public, except as allowed by law. Confidential data is available to
neither you nor the public. The personal information we collect about you is private, including: Birth
date, marital status, social security number, sex, children, spouse, private physician, financial data,
medical history data, physical assessment data, nursing diagnosis, care plan, and health history
We use this information to enable the Washington County Chemical Health Unit to prepare a
comprehensive plan for care using pertinent chemical health information and to determine whether
you are eligible for financial aid or community services. The Washington County Chemical Health Unit
consists of staff from the following: Washington County Community Services Chemical Health Unit.
Furnishing the above stated information is voluntary but refusal to supply requested
information will mean limited services being available to you and/or your family.
The data supplied by you may be used for other purposes as determined to be necessary in the
administration of community-based services in Washington County.
Private data is available only to you and to other persons in governmental office and agencies
who have a bona fide need for the data or persons and entities who are granted access by court order,
state or federal law, or your written consent. Persons or agencies with whom this information may be
shared include medical providers and hospital staff. Unless otherwise provided by law, before this
information is shared, you will be asked to whom and what information you are allowing to be shared
by signing a Consent for Release and Exchange of Information form.
Client/Guardian Signature Date
Name (Witness) Date
Service Center Cottage Grove Service Center Forest Lake Government Center Service Center Woodbury
13000 Ravine Parkway 19955 Forest Road N 14949 62nd St N P.O. Box 30 2150 Radio Drive
Cottage Grove, MN 55016 Forest Lake, MN 55025 Stillwater, MN 55082-0030 Woodbury, MN 55125
Phone: 651-430-4159 Phone: 651-275-7260 Phone: 651-430-6455 Phone: 651-275-8650
Fax: 651-430-4157 Fax: 651-275-7263 Fax: 651-430-6605 Fax: 651-275-8682
Washington County is an equal opportunity organization and employer