Get Wa Dshs 17-063 2011

Filling out the WA DSHS 17-063 form is an essential step for individuals who want to authorize the disclosure of confidential information held by the Department of Social and Health Services. This guide provides a clear, step-by-step approach to help you complete the form online effectively.

Follow the steps to complete the form with ease.

1. Click ‘Get Form’ button to obtain the form and open it in your document editor.
2. Begin by entering the name of the individual whose records you wish to disclose. Fill in the last name, first name, and middle name as applicable.
3. Provide additional information to help locate the records, including the client identification number, date of birth, former names, and any other identification numbers that may assist.
4. Specify the dates and locations of service related to the records you wish to disclose for precise identification.
5. In the section labeled 'Disclose To', fill in the name, title, organization or business name (if applicable), address, city, state, zip code, telephone number, and email address of the individual or organization that will receive the records.
6. Indicate the reason for the disclosure in the provided field, as this is necessary for sharing certain records like those related to mental health or substance use.
7. In the ‘Authorization’ section, select the DSHS programs that you authorize to disclose your records. If not listed, utilize the 'Other' field to specify any additional programs.
8. Define which DSHS records you are allowing to be disclosed. You can choose to release all records or limit it to specific types or time periods.
9. If applicable, check the box for any special records that include sensitive information, such as HIV or mental health records.
10. Specify the duration of this authorization, which can be set for a maximum of 180 days or until a specified date or event.
11. Review all entered information for accuracy and completeness before proceeding.
12. Sign the form as the authorized person, providing your contact information and the date signed.
13. If you are signing on behalf of another individual, indicate your relationship to them and attach the necessary proof of authority.
14. Include a witness or notary signature if required, particularly if you are not submitting the form in person.
15. Once completed, save any changes to the form, and you will have options to download, print, or share the filled form.

Complete your WA DSHS 17-063 form online today to facilitate the disclosure of your records.