Data Practices Rights Advisory CDTennessen Warning 7 2011 by z8OBCl


									                                                                                                        Community Services
                                                                                                        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

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