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Washington Medical Records Release Form 2

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This form is provided by The Everett Clinic to authorize the disclosure or release of one person's protected health information.

Washington Medical Records Release Form 2
Washington Medical Records Release Form 2
Distribution: white—scan yellow—requestor pink—patient 10-009 4/12
Health Information Management
Fax: 425-339-5439 Phone: 425-339-5426
AUTHORIZATION FOR THE RELEASE OF MEDICAL INFORMATION
Please read all information and instructions before completing and signing the authorization form.
Patient’s Name ___________________________________________________________ Birth date _______________________
(Please Print) LAST FIRST MI
Are medical records filed under another name ____________________________ Phone Number _________________________
INFORMATION TO BE RELEASED BY:
INFORMATION TO BE RELEASED TO:
The Everett Clinic
_____________________________________________
Organization/Person Name
________________________________________________
Street Address City, State, Zip
________________________________________________
Phone Fax
The Everett Clinic
_______________________________________________
Organization/Person Name
_________________________________________________
Street Address City, State, Zip
_________________________________________________
Phone Fax
TYPE OF MEDICAL INFORMATION REQUESTED:
Complete medical record abstract (includes 3 years of chart notes, most recent labs/pathology & diagnostic imaging reports)
Cancer Partnership records Radiology/ Diagnostic Imaging (CD/Films) Mammogram Diagnostic Imaging (CD/Films)
Echocardiograms Pharmacy Behavioral Health records only
My health information relating only to the following treatment or condition: ___________________________________________
My health information only for the following date(s): _____________________________________________________________
Other: ________________________________________________________________________________________________
SENSITIVE INFORMATION: This authorization includes the release of the following sensitive information unless specifically
excluded. Please check if you do not
want this released: Mental health HIV/AIDS Sexually transmitted diseases
Drug and alcohol treatment Reproductive care (minors only) Self-paid services
REASON FOR REQUEST: Personal Transfer of Care Disability Insurance Legal Review
Other (please explain): __________________________________________________________________________________
MINORS AGE 13-17: A minor patient’s signature is required in order to release the following information: (1) conditions relating to
the minors reproductive care including, but not limited to: contraception, pregnancy, and pregnancy termination, sterilization, and
sexually transmitted diseases (age 14 and older), (2) alcohol and/or drug abuse (age 13 and older), and (3) mental health conditions
(age 13 and older).
I hereby consent to the release of the specified information relating to diagnosis, testing or treatment to the person or entity named
above. I understand that such information cannot be released without my informed consent. I acknowledge I have fully reviewed and
understand the contents of this authorization form. My signature below indicates that I hereby agree to and authorize the release of
patient health information to the above named person or organization. You have the right to revoke or cancel this authorization, in writing,
at any time.
THERE MAY BE A CHARGE FOR COPIES OF YOUR MEDICAL RECORD UNLESS YOUR
COPIES ARE BEING SENT TO ANOTHER PHYSICIAN OR HEALTHCARE FACILITY.
This authorization expires _________________________ (date or event). Authorization will expire in 90 days if not otherwise specified.
Patient signature __________________________________________________________________ Date ________________
Parent or Legal Guardian____________________________________________________________ Date ________________
Relationship to patient, if other than patient _______________________________________________________________________________
(You may be required to provide legal documentation as proof for power of attorney or guardianship)
Federal laws prohibit the recipient 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.
MRN: ________________________________
ROI Status: Processed Returned to Requester Encounter
Chart Review Return Letter Date: _________________
Document(s) released in accordance with scope of patient request
Date records were provided: _________________
@10-009@
INTERNAL USE ONLY:
Washington Medical Records Release Form 2
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