HTML Preview Generic Medical Records Release Form page number 1.
Distribution: white—scan yellow—requestor pink—patient 10-009 7/14
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:
REQUEST MUST HAVE COMPLETE ADDRESS OR FAX NUMBER
_____________________________________________
Organization/Person Name
________________________________________________
Street Address City, State, Zip
________________________________________________
Phone Fax
REQUEST MUST HAVE COMPLETE ADDRESS OR FAX NUMBER
__________________________________________
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: ________________________________________________________________________________________________
REASON FOR REQUEST: Personal Transfer of Care Disability Insurance Legal Review Continuing Care
Other (please explain): __________________________________________________________________________________
I understand that the information in my health record may include information relating to sexually transmitted disease, acquired
immunodeficiency syndrome (AIDS), or human immunodeficiency virus (HIV). It may also include information about behavioral or
mental health services, and treatment for alcohol and drug abuse or self-paid services. You are hereby specifically authorized to
release all information or medical records relating to such diagnosis, testing, or treatment, unless specifically excluded below.
_________________________________________________________________________________________________________
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. I understand that I do not have to sign this
authorization in order to get health care benefits (treatment, payment, enrollment, or eligibility for benefits).
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 and state laws prohibit the recipient from making any further disclosure of this information unless further disclosure is expressly permitted by
written consent of the person to whom it pertains. A general release is NOT sufficient. 42 CFR Part 2: RCW 70.02.300
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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: _________________
INTERNAL USE ONLY: