AUTHORIZATION FOR RELEASE OF MEDICAL RECORDS

Patient Information:

_________________________________ DOB: ______________ SS#: ___________________________
	(PRINT name of patient)

Information to be released from: 	_________________________________________________________
					Name of designated recipient

				______________________________________________________________________
						Address

				__________________________________________________   _(___)_____________
					City, State, Zip Code				Phone Number
	
				_(____)________________________
					Fax Number

Information to be sent to: 		Dedicated Women’s Health Specialist
					1701 3rd ST SE Suite 200
					Puyallup, WA 98372
					(253) 840-4444	FAX (253) 840-5239	
Information to be released:
 The most recent 2 years of pertinent information (Chart notes, labs, x-rays, and special tests)
 All medical records
 Specific information (Please specify): _______________________________________________________
    __________________________________________________________________________________

Purpose for which disclosure is being made:  (Please check one of the following)

	   Attorney 	   Insurance	   Doctor		   Personal

Patient Authorization:
I understand that my records may contain information regarding the diagnosis or treatment of HIV/AIDS, sexually transmitted diseases, drug and/or alcohol abuse, mental illness, or psychiatric treatment. I give my specific authorization for these records to be released.

	* EXCLUDE the following information from the records released (please initial):
______ Drug/Alcohol abuse/treatment & diagnosis	_____ Sexually Transmitted Disease

_____ HIV/AIDS diagnosis/treatment/testing           ____ Mental Illness or Psychiatric diagnosis/treatment

My rights:
I understand I do not have to sign this authorization in order to obtain health care benefits (treatment, payment or enrollment). I may revoke this authorization in writing. To view the process for revoking this authorization, please read the Privacy Notice to patients posted at the facility where your information is being released. I understand that once the health information I have authorized to be disclosed reaches the noted recipient, that person or organization may re-disclose it, at which time it may no longer be protected under Privacy laws.

SIGNATURE: _________________________________________________ DATE: ________________
		(Patient, Guardian*, or Authorized Representative*)
		[Please provide documents to prove authority to sign on behalf of the patient.]

			This authorization will expire 90 days from the date signed.
				Possible copying fee required