AUTHORIZATION TO RELEASE HEALTH INFORMATION

AUTHORIZATION TO RELEASE HEALTH INFORMATION
I. PATIENT INFORMATION
Name*
Date of Birth*

MonthDayYear
Date
Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Phone*
II. RELEASE OF INFORMATION
Please complete all fields in order for request to be processed.*

I authorize White Memorial Community Health Center to release information to:I authorize White Memorial Community Health Center to obtain information from:
Facility receiving health information*
Name of person
Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Phone*
Please enter a valid phone number.
Fax
Please enter a valid fax number.
Email
example@example.com
Information to be released:*

All health recordsHealth records for the following dates:Health records for the following conditions:Other (X-ray, billing, etc):
Dates:
Conditions:
You may release information regarding testing diagnosis, and treatment for (check all that apply):

HIV/AIDS virusSexually transmitted diseasesDrug and /or alcohol usePsychiatric disorders/Mental Health
Reason for the release:*

PersonalDoctorAttorneyInsuranceType option 5Other
III. PATIENT'S RIGHTS
I understand that I do not have to sign this authorization in order to get health care benefits (treatment, payment, or enrollment I may revoke this authorization in writing. If I do, it will not affect any actions already taken by White Memorial Community Health Center (WMCHC) based upon this authorization. I may not be able to revoke this authorization if its purpose was to obtain insurance. To revoke this authorization, I must write a letter to WMCHC. This information may be subject to redisclosure and may no longer be protected by federal or state privacy laws.

This authorization expiresDate (if left unsigned, the 1 year from date of this authorization or as required inRCW70.02.030(6), whichever is shorter.)
Patient or legally authorized individual signature*

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Date*

MonthDayYear
Date
Printed Name*
Relationship to patient*
Other
Should be Empty:

AUTHORIZATION TO RELEASE HEALTH INFORMATION

I. PATIENT INFORMATION

II. RELEASE OF INFORMATION

III. PATIENT'S RIGHTS