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Patient Authorization to Disclose, Release and/ or obtain protected Health information 1. Patient information Name- Last, First, MI Former Name(s)/Alias: Street Address City State Zip Medical Record Number (if known) Birthdate Phone Number 2. Purpose or need for disclosure - may be released electronically. (Please check all applicable categories). Attorney Insurance Provider Personal Other (specify)__________________. 3. Records to be released from: Harborview Medical Center & Clinics Northwest Hospital and Medical Center & Clinics UW Medical Center & Clinics Valley Medical Center & Clinics UW Neighborhood Clinics Hall Health Center Other: ________________________________________ ________________________________________ ______________________. ________________________________________ ________________________________________ ______________________________.

AUTH TO DISCLOSE/OBTAIN PHI UH0626 REV JAN 22 BACK 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

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