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AUTHORIZATION FOR THE RELEASE OF MEDICAL ... - …

INTERNAL USE ONLY: MRN: _____. ROI Status: Processed Returned to Requester Encounter Chart Review Return Letter Date: _____. Document(s) released in accordance with scope of patient request Health Information Management Fax: 425-339-5439 Phone: 425-339-5426 Date records were provided: _____. 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 REQUEST MUST HAVE COMPLETE ADDRESS OR FAX NUMBER.

INSTRUCTIONS & IMPORTANT INFORMATION Please read all information and instructions before completing and signing the authorization form. THERE MAY BE A CHARGE FOR COPIES OF YOUR MEDICAL RECORD UNLESS YOUR COPIES ARE BEING SENT TO ANOTHER PHYSICIAN OR HEALTHCARE FACILITY. Many patients ask The Everett Clinic …

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AUTHORIZATION FOR THE RELEASE OF MEDICAL …

www.everettclinic.com

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

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Instructions for Form I-539, Application Department of ...

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