CANCELLATION REQUEST / POLICY RELEASE DATE …
cancellation request / policy release reason for cancellation mortgagee loss payee cancellation request (policy attached) policy release (complete statement section below) phone (a/c, no, ext): cancelled policy information policy release statement for agency/company use method of cancellation name and address request/release distribution acord ...
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www.everettclinic.com4. If the release has been accomplished, you will be notified by a representative of the Health Information staff. The release will be revoked for any further disclosure. 5. If you have any questions concerning the cancellation process, call the Health Information Management (Medical Record) Department (425) 339-5426 extension 2171 or 2321.