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Washington Medical Records Release Form 3

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This form is provided by Olympic Medical Center to authorize the disclosure or release of one person's protected health information.

Washington Medical Records Release Form 3
Washington Medical Records Release Form 3
AUTHORIZATION TO DISCLOSE
PROTECTED HEALTH INFORMATION
Olympic Memorial Hospital | Olympic Medical Physicians | Olympic Medical Home Health
PATIENT INFORMATION
Patient Name (printed): Previous Name(s):
Date of Birth: Daytime Telephone Number:
SEND INFORMATION TO: (please be specific)
Provider Name/Organization:
Address:
City: State: Zip:
Phone #: Fax #:
INFORMATION TO BE RELEASED FROM: (please be specific)
Provider Name/Organization:
Address:
City: State: Zip:
Phone #: Fax #:
PURPOSE OF DISCLOSURE
Transfer of Care Self Specialist Other (must complete)
Medical Records from last two years
Limited Health Information or Documentation Dates of Service:
Complete Medical Chart Contents
Other Expiration Date (or event)
(No more than 90 days forward)
CONSENT TO DISCLOSE
If the patient is unable to sign, please indicate such and the authority to act of the person who is signing for the
patient. This form must be dated within 90 days of receipt, and may be revoked at any time, providing the
information has not already been disclosed. Please see our Notice of Privacy Practices for instructions as to
how to revoke this authorization. We will not condition treatment on the completion of the authorization. Also,
please be aware that once we disclose this information per your instructions the information is subject to
re-disclosure and may no longer be protected by the HIPAA of 1996.
Date Signature of patient or representative Relationship to patient
DISCLOSURES REQUIRING SPECIAL CONSENT
My signature below specifically authorizes the release of healthcare information relating to the testing, diagnosis, or
treatment for (Please initial beside the specific information to disclose):
HIV/AIDS Virus Mental Health/Psychiatric Disorders
Sexually Transmitted Diseases Drug, Alcohol Abuse/Treatment
Date Signature of patient or representative Relationship to patient
FOR FACILITY USE ONLY
Date Received:______________ Date Information Released:______________ Chart #:_________________
Person/Department Sending Records: ______________________________________________________________
HIM09270 3-09
Washington Medical Records Release Form 3
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