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AUTHORIZATION TO RELEASE/OBTAIN/EXCHANGE …

( )PATIENT LABELr*44036*r4403644036 (12/2021) Page 1 of 2 AUTHORIZATION TO release /OBTAIN/EXCHANGEPATIENT HEALTH INFORMATIONO riginal Copy: Chart Copy: Legal Representative/PatientAuthorization To RELEASE/OBTAIN/EXCHANGE Patient Health InformationPatient Name: (Legal Name)Date of Birth:LastOther Names Used:Medical Record Number:FirstMiddle(if applicable)MonthDayYear(if known)I authorize Seattle Children s Hospital to:Organization/Recipient/PersonAddress: Attn:City:State:Zip Code:Email:Fax #:Phone #:oRelease TooObtain FromoExchange With (Verbal Information Only)( )(required for CD and electronic delivery)Paper copies will be mailed to the recipient unless another format is checked below:oCD (compact disc)oSecure Email (patient/family only)Please indicate the purpose(s) of your request:oContinuing CareoTransfer of CareoPersonal UseoLegaloInsuranceoSchooloDisabilityoOt her (please provide details):Records for Dates:FromTooInpatient Hospital StayoOutpatient Clinic/Emergency DepartmentoLab & Radiol

If it was indicated on the authorization that the records will be picked up once copied, the Health Information Integrity department will contact you when the information that you requested is available. Please ensure that the person picking up records, is the same person that is listed on the authorization in the “Release” section.

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