Get Wa Dshs 17-063 2019-2026

Filling out the WA DSHS 17-063 form is a straightforward process, allowing you to authorize the disclosure of confidential records. This guide will provide you with a clear, step-by-step approach to complete the form effectively and efficiently.

Follow the steps to successfully complete your authorization form.

1. Click ‘Get Form’ button to access the form and open it for editing.
2. Fill in the identification of the individual whose records are being requested. Input their full name, including last, first, and middle names, as well as their date of birth. This information is essential for locating the correct records.
3. Provide any optional information that may assist in record location, including former names, client identification number, other identification numbers, dates, and locations of services.
4. Complete the section for the person or organization receiving the records. Include their name, title, organization or business name, address, telephone number, city, state, zip code, and email address.
5. If applicable, specify the reason for disclosure, which is required for sharing specific sensitive records.
6. In the authorization section, select the appropriate DSHS programs that you authorize to disclose information. You may check all that apply or select to disclose all records held by DSHS.
7. Indicate what records you authorize for disclosure by selecting from the provided options. You may also specify limits, such as by date or type of record, if necessary.
8. If any records contain sensitive information (e.g., HIV/AIDS, mental health), complete the special records section to allow disclosure of these specific records.
9. Sign the authorization section, indicate the date signed, and provide your contact number. If you are signing for another person, indicate your authority and include proof as required.
10. If needed, have a witness or notary sign and print their name to verify identity. This may be required depending on how you submit the form.
11. Once all fields are completed, save your changes. You can then download, print, or share the completed form as needed.

Start filling out the WA DSHS 17-063 form online today to ensure your records are disclosed as authorized.