Authorization to Release Healthcare Information

Patient Name*

First NameMiddle NameLast NameSuffix
Patient Date of Birth*

MonthDayYear
Approximate Date of Call/Treatment*

MonthDayYear
I request and hereby authorize The City of Walla Walla – Fire/Ambulance Department to release the following medical information:*

Ambulance Care ReportAmbulance Bills
Which medical information to release
Where do the records need to go?
Name of Individual or Agency Requesting Records*
Mailing Address*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip CodeCountry
Phone Number*
Please enter a valid phone number.Format: (000) 000-0000.
Health records needed for the purpose of:*

Personal filesTo process insurance claimsOther
Purpose of health record release
Permission to Fax*

No, I don't want my records faxedYes, I want my records faxed. (Please enter your initials and the recipient's fax number in the box below.)
Enter your initials*
Enter recipient's fax number*
Please enter a valid phone number.Format: (000) 000-0000.
Please note before completing the next question:

PUBLIC DISCLOSURE NOTICE TO RECIPIENT(S): Information contained in any communication to or from the City of Walla Walla, including attachments, may be subject to the disclosure requirements of Washington’s Public Records Act, Ch. 42.56 RCW.
Permission to send confidential health records electronically through the internet via email*

No, I don’t want my records sent electronically.Yes, I want my records sent electronically. (Please enter your initials and the recipient's email address in the box below.)
Enter your initials*
Enter recipient's email address*
Authorization / Autorización
This authorization to release protected healthcare information will expire within 90 days from time of signature. I may revoke this authorization in writing at any time, provided that the information has not yet been released. To view the process for revoking this authorization, please read the Privacy Notice. I understand that once the City of Walla Walla – Fire Department discloses health information, the person, or organization that receives it may re-disclose it, at which time it may no longer be protected under Privacy Laws. I understand that my records may contain information regarding the diagnosis or treatment of HIV/AIDS, sexually transmitted diseases, drug and/or alcohol abuse, mental illness, psychiatric treatment, or genetic information. I give my specific authorization for these records to be released. OR Exclude the following information from the records released. Esta autorización para divulgar información médica protegida expirará en un plazo de 90 días a partir del momento de la firma. Puedo revocar esta autorización por escrito en cualquier momento, siempre que la información no haya sido divulgada todavía. Para ver el proceso de revocación de esta autorización, por favor lea el Aviso de Privacidad. Entiendo que una vez que la Ciudad de Walla Walla - Departamento de Bomberos divulga la información de salud, la persona, u organización que la recibe puede volver a divulgarla, momento en el cual puede dejar de estar protegida por las Leyes de Privacidad. Entiendo que mis registros pueden contener información sobre el diagnóstico o tratamiento de VIH/SIDA, enfermedades de transmisión sexual, abuso de drogas y/o alcohol, enfermedades mentales, tratamiento psiquiátrico o información genética. Doy mi autorización específica para que se divulguen estos registros. O Excluya la siguiente información de los registros divulgados.
Check each that should not be released:

Drug/Alcohol abuse/treatment and diagnosisSexually Transmitted DiseaseGenetic InformationHIV/AIDS diagnosis/treatment/testingMental Illness or Psychiatric Diagnosis/Treatment
Do not release
Signer is:*

SelfParentLegal Guardian (Please provide documents to prove authority to sign on behalf of the parent)Authorized Representative (Please provide documents to prove authority to sign on behalf of the patient)
Attach documents here*

Cancelof
Signature*
Name of Person Who Signed*

First NameLast Name
Enter Today's Date*

MonthDayYear
Should be Empty:

Where do the records need to go?

Please note before completing the next question: