All clients should recognize that data released is confidential, and is provided only for the specified purpose approved by this request. Any dissemination of data to persons/groups external to this agreement is prohibited in accordance with the Health Information Act of Alberta.

By signing this form, the requestor and recipient agree to:
• Ensure the security and confidentiality of the data is maintained;
• Use the data only as specified;
• Acknowledge WCCHN as the data source;
• Not contact any person whose information is in the WCCHN, unless prior written authorization of Alberta Health Services has been obtained; and
• Agree to limit the contact with any such person to the extent authorized by Alberta Health Services.

This request is valid for 12 months from the date authorized by WCCHN, or until the information is released.

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