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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 & Radiology ReportsoOperative/Procedure NotesoRadiology Images (on CD)oBilling RecordsoPsychiatric Summary/Care PlanoE

Signing this release of health information is voluntary; I do not need to sign this form for treatment or payment. Any disclosure of information has the potential for further release or distribution by the recipient that may not be protected by confidentiality laws.

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