Get Wa The Everett Clinic Authorization To Release Medical Records 2021-2025

The WA The Everett Clinic Authorization To Release Medical Records form is essential for ensuring your medical information is shared securely and appropriately. This guide will provide you with clear, step-by-step instructions on how to complete this form online, making the process efficient and accessible.

Follow the steps to complete the authorization form online.

1. Click the ‘Get Form’ button to access the document and open it in your preferred electronic editor.
2. Fill in the patient information section, including the patient's name (be sure to include any maiden or other names), date of birth, and social security number.
3. In the 'Information to be released from' section, enter the name and address of the healthcare facility or provider.
4. For the 'Information to be sent to' section, provide the name of the designated recipient along with their fax number, city, address, state, and zip code.
5. Indicate if you want to release to your active MyChart account and/or through a secure portal by checking the corresponding boxes and initialing.
6. If applicable, include your email address in the designated area.
7. In the 'Information to be released' section, select one option by checking the appropriate box: 'the most recent 2 years of pertinent information,' 'all medical records,' or 'specific information' (with specification).
8. For the 'Purpose for which the disclosure is being made' section, check the applicable box that reflects your reason for the request.
9. Review the patient authorization statement carefully. You may choose to exclude certain sensitive information by initialing the relevant sections.
10. Sign the form where indicated, and include the date of signature. This can be completed electronically if your platform allows it.
11. Once you have completed the form, you can save changes, download it for your records, print it, or share it as required.

Complete your authorization to release medical records online today and ensure your healthcare information is shared safely.