Instructions for Completing the Wyoming Department of Health Authorization to Release Health Records
Client:
 - Print the client’s – full, legal name &/or any previous names
 - Address & previous address (if applicable)
 - If you would like a previous address changed to the current address, check the box.
 - Date of birth
 - Client’s phone number (if we have questions)

Information Released FROM: Select the Wyoming Department of Health (WDH) divisions/programs/facilities you want to release your health information.
Information Disclosed TO: Print the name of the individual/facility/organization who is to receive the information along with their full/complete address, city, state, and contact number. If the information is being released directly to the client, select self.
Delivery Method: Select how we should send the information. Only the patient may pick up the information, unless the patient authorizes a designee.  The WDH division/program/facility will call the client’s phone number to provide notification that records are ready to be picked up and confirm pick up location.
Information to be Released: Specify the records to be released. Include dates if possible.
Purpose of Disclosure: Select the purpose of disclosure.
Expiration: The authorization will expire in one year unless specified otherwise.
Mail, fax, or email the completed and signed authorization with proof of identity (photo ID, Driver's license) to:

FREMONT COUNTY PUBLIC HEALTH                                                                 FREMONT COUNTY PUBLIC HEALTH
450 N 2ND, ROOM 350                                                                                        818 SOUTH FEDERAL
LANDER, WY  82520                                                                                            RIVERTON, WY  825201
FAX: 307-332-1064                                                                                              FAX: 307-856-6850
phnriverton@wyo.gov

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