Medical Release

Authorization to Release Records

Patient Authorization to Disclose, Release and/or Obtain Protected Health Information. PLEASE FILL OUT ALL SECTIONS TO AVOID DELAYS IN PROCESSING
Name*

First NameLast Name
Former Name (s)/Alias:
Email
example@example.com
Medical Record Number (if known)
Address*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Birthdate*
Phone*
Purpose or need for disclosure - may be released electronically. (Please check all applicable categories)*

AttorneyInsuranceProviderPersonalOther
Records to be released from:*

Retina Institute of WAOther
Phone Number
Please enter a valid phone number.
Fax Number
Please enter a valid phone number.
Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Records to be disclosed to: (e.g. insurance Company, Attorney, Physician, Patient)*
Name
Telephone*
Fax
Address*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Records to be disclosed:

Comprehensive overview of chart (contacts visit summaries, diagnostic tests, operative notes)ImagesOther
Dates needed (if timeframe not specified most recent 2 years of medical records will be provided)
Specify image type (e.g. external photos, OCT, VF)
Specify other (e.g. discharge summary, operative records, lab reports, billings records, or entire legal health record)*
I authorize VERBAL COMMUNICATION ONLY about my medical history and care. (Checking this box means no physical records will be sent unless otherwise indicated by Checking additional boxes in sections 5 & 7)
Patient Authorization: Unless otherwise indicated, I authorize sensitive information about my conditions, which may include sexually transmitted disease, acquired immunodeficiency syndrome (AIDS), or human immunodeficiency virus (HIV). My health record may also include sensitive information about behavioral or mental health services and treatment for alcohol and drug abuse.

Do not Include this sensitive information.
Format for Records: (If VERBAL COMMUNICATION ONLY, this item may be skipped.)

Paper (Fees may apply)Flash Drive ($10 charge)Email
This authorization is in effect until the below date, OR 90 days from the date signed
Note: Authorizations to disclose your information to an employer or financial institution can only be effective for a maximum of one year from the date signed by you
Signature (Patient or person authorized to give authorization) *

Powered by Jotform SignClear
Date

MonthDayYear
Date
If signed by person other than patient, provide printed name, reason, relationship to patient, description of their authority
By signing this page, I acknowledge that I have read and agree to the terms on both sides of this form.
Patient Authorization to Disclose, Release or Obtain Protected Health Information

Minors: A minor patient's signature is required in order to release the following information (1) conditions relating to the minor's reproductive care (2) sexually transmitted diseases (if age 14 and older), (3) alcohol and/or drug abuse and mental health conditions (if age 13 and older).

Patient Rights: I understand I do not have to sign this authorization in order to obtain healthcare benefits (treatment, payment, or enrollment). I may revoke this authorization at any time except to the extent already relied upon by sending a request in writing to Retina Institute of Washington 4300 Talbot Road S, Suite 300 Renton, WA 98055. I understand that once the health information I have authorized to be disclosed reaches the noted recipient, that person or organization may re-disclose it, at which time it may no longer be protected under privacy laws.

I understand I have the following rights to:

• Inspect or to receive a copy of my protected health information
• Receive a copy of this signed form
• Refuse to sign this form for authorization to disclose or release my protected health information

Please complete this form and return it to Retina Institute of Washington.

This authorization form can be sent to us by mail or by fax. If the patient chooses to accept the risks associated with unencrypted email (that email communications could potentially be read by a third party), the form may be sent by email.

Retina Institute of Washington
4300 Talbot Rd S #300
Renton, WA 98055
Fax: 425-228-6260
Email: MedicalRecords@RetinalnstituteWA.com
Should be Empty:

Authorization to Release Records