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Do not include this sensitive information

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 . WHITE – MEDICAL RECORD CANARY – PATIENT . UH0626 REV JAN 22. 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.

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