Release of Information Form

This secure form allows you to authorize Wilson Housing Alliance to release your information to specified parties. Please choose one of the two options below.

Option 1: Complete Online (Recommended)

Fill out the form directly on this website. Your progress will be saved automatically. When you are finished, a completed PDF will be securely submitted to us, and a copy will be available for your records.

Option 2: Manual Download

Download a blank PDF form to print and fill out by hand. After completing it, you will need to scan and email it to [email protected].

Download Blank Form

Authorization for Release of Information

Click to Read Full ROI Instructions

ROI's must be completed in blue or black pen to be processed. All writing must be legible for records to be released. The ROI form allows Wilson Housing Alliance to communicate with providers or parties involved in your treatment, legal case, or recovery plan. This information may be necessary to confirm eligibility, monitor progress, or coordinate services. You have the right to limit what information is released and to whom. Signing the ROI is voluntary but may impact our ability to assist you if not completed.

Applicant's Information: On the top of the ROI, it will ask for applicant's name and Date of Birth (DOB). Applicants name must include both first and last name for the request to be fulfilled. If the applicant has a previous last name, you will need to complete a separate, independent ROI form to request the records for each name.

Person/Agency Receiving Information: This section must include the complete name of the person we will be releasing records to. If the person requesting the records is the same person we will be releasing to, we will still need the complete name. All ROI's must include the complete mailing address in this section for release. We use this for verification and an alternative method of release in case we are unable to fax or email. If you would like records emailed or faxed, the email address will need to be provided in this section. Please make sure that they are clear and legible. If there is a preferred method you would like the records to be released, please circle the preferred method of release in this section. We will attempt to accommodate all requests; however, may be denied due to fax and email limitations. If we are unable to release by fax/email, we would then mail the records out or prepare for pick-up if the option is checked off on the ROI form.

Information to be disclosed: This section indicates which specific records you are authorizing for release. If you are still unsure which one to check off, please feel free to use the "Other" option and write which records you are authorizing for release.

Dates of Records: ROI's can be used for extended release for up to a year, if there are no changes. If you would like to use this option, you will need to complete the section that states, "I revoke this authorization" and either use the date that is 1 year from the date you are signing the ROI form or you may check off one of the other options listed in this section.

Name *

Date *

Person/Agency authorized to make the disclosure:

Wilson Housing Alliance
4920 Evergreen Way South #1106
Everett WA 98203

Person/Agency Receiving the Information

Name *

Phone # *

Address *

E-mail *

Pick Up

Fax #

Dates of Records

From:

to:

OR if no dates,

years will be released.

Check here if each of the above parties may disclose your information with the other party. The above information may include records of drug abuse, alcoholism, medical history, criminal history, residency history.

This acknowledgement is required.

Purpose for Disclosure: *

I understand I may revoke this authorization at any time by writing to Wilson Housing Alliance. The revocation will be effective except to the extent that action based on this authorization has already been taken. Wilson Housing Alliance may not condition eligibility for housing on whether the consumer signs the authorization. The information used or disclosed by this authorization may be at risk for re-disclosure by the recipient and no longer protected by federal privacy laws.

This consent will expire (Check both): *

Upon denial of application for residency

Upon termination of residency

Both expiration conditions must be checked.

Signature of Applicant *

A signature is required.

Printed Name *

Date of Signature *

Notice: Alcohol and drug abuse patient records are protected by Federal confidentiality regulations (42 CFR part 2). The Federal regulations prohibit you from making any further disclosure of this information unless further disclosure is expressly permitted by the written consent of the person to whom it pertains or as otherwise permitted by 42 CFR part 2. A general authorization for the release medical or other information is NOT sufficient for this purpose. The Federal regulations restrict any use of the information to criminally investigate or prosecute any alcohol or drug abuse patient. Communicable disease related information, pursuant to this release, cannot be re-disclosed without specific authorization. (A.R.S. 36-664.H)

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