Get Dshs 17 063 Form

This guide provides clear, step-by-step instructions for filling out the DSHS 17 063 form online. Whether you are requesting disclosure of your records or those of another person, this guide will help you navigate each section confidently.

Follow the steps to complete the DSHS 17 063 form accurately.

1. Press the ‘Get Form’ button to access the DSHS 17 063 form online.
2. In the identification of subject of records section, input your full name or the name of the person whose records you are requesting. Ensure to include their last, first, and middle names.
3. Fill in the date of birth to assist in identifying the correct records.
4. Optional: Include any former names that have been used when receiving benefits or services to aid in record retrieval.
5. Optionally provide any client identification number or other identifiers that can help locate the records, such as a social security number if necessary.
6. Specify the dates and locations of services to further assist DSHS in finding the correct records.
7. Complete the ‘disclose to’ section with the information of the person or organization receiving the records, including their full name, title, organization, address, city, state, zip code, telephone number, fax number, and email address.
8. You may optionally provide a reason for disclosure. This is required for disclosing drug and alcohol or mental health records.
9. In the authorization section, mark which parts of DSHS you wish to allow to disclose your records. You may either check specific programs or select 'All parts of the Department of Social and Health Services.'
10. Indicate what specific records you want shared. You may opt for all client records or specify particular records or any limitations necessary.
11. If applicable, check any specific types of sensitive records you are allowing to be disclosed, such as HIV/AIDS, mental health, or chemical dependency records.
12. Sign and date the authorization section. If signing on behalf of someone else, indicate your relationship and attach proof of authority if necessary.
13. If needed, have a witness or notary sign the form in the designated section.
14. Once completed, review the form for accuracy, then save your changes, download, print, or share the form as required.

Complete the DSHS 17 063 form online today to ensure timely access to your records.