Sara Riel Inc. Authorization for Release of Information
BY AGREEING BELOW, I UNDERSTAND THAT…
• Sara Riel Inc. may require to both obtain and share my private health and financial information, social and psychiatric assessments, admission and discharge summaries, progress notes, etc., as necessary, in order to determine my acceptance, and continued eligibility, to Sara Riel Inc. for the provision of services.
• Sara Riel Inc. may also be required to share certain information with their funding agents (Government
of Manitoba and Winnipeg Regional Health Authority) in the ongoing provision of services.
• My confidential information may be shared with the proper emergency services, if Sara Riel Inc. has justifiable reason to believe that maintaining confidentiality may result in serious threat to the health
and safety of me and/or another person.
• My confidential information may be shared with the proper emergency services, if I am incapacitated and/or unable to provide information required to ensure that I receive appropriate care.
• Sara Riel Inc. staff are bound by confidentiality agreements as part of their condition of employment,
and may only use my information to provide services to me as I have agreed.
• I may revoke my authorization to share my private information with any and all of the “persons or organizations listed herein”*, at any time, by way of a written ‘notice of change’.
• Sara Riel Inc. to release my intent to receiving supports from Sara Riel Inc., and to request
necessary information regarding my application from the “persons or organizations listed herein”*.
• The release of the requested information from the “persons or organizations listed herein”*,
to Sara Riel Inc., for the purpose of receiving supports from Sara Riel Inc.
• I attest that I am the full age of majority.
• I release Sara Riel Inc., including its employees, agents, students, researchers and volunteers, from any and all claims whatsoever which may arise as a result of the release of information.
• I ensure that all of the information provided in this application is accurate to the best of my ability.
• We have the duty to report if life or safety is seriously threatened or disclosure is required by law. This duty supersedes all confidentiality and authorizations.
