Medical Release Form
(Pursuant to RCW 42.17 and RCW 70, Effective July 28, 1991)
HEALTH CARE FACILITY of:
Your patient, ____________________________________,
hereby authorizes you to make the following disclosures:
DISCLOSURE TO BE MADE TO my attorney, or any representative on their behalf authorized in writing by said attorney, to wit: Injury At Sea, 4705 - 16th Avenue N.E., Seattle, Washington 98105, (206)527-8008. In this regard, I waive any physician/patient privilege to my attorney named above and at the address and telephone number also provided therein.
Any future disclosure may be in writing or in oral conversations at the option of my attorney.Your full cooperation with my attorney is requested and appreciated.
DISCLOSURE NOT TO BE MADE TO any other persons, including insurance agents, insurance adjusters and other attorneys.If such request is made, please call my attorney named above.
NATURE OF INFORMATION TO BE DISCLOSED all health care information as defined in Sec. 102 of the Uniform Health Care Information Act, restated herein as follows: "...any information, whether oral or recorded in any form or medium, that identifies or can readily be associated with the identity of a patient and directly relates to the patient's health care. The term includes any record of disclosures of health care information."
SPECIFIC RELEASE I understand that my express consent is required to release any health care information relating to testing, diagnosis, and/or treatment for HIV (AIDS virus), sexually transmitted diseases, psychiatric disorders/mental health or drug and/or alcohol use.If I have been tested, diagnosed or treated for HIV (AIDS virus), sexually transmitted diseases, psychiatric disorders/mental health or drug and/or alcohol use, you are specifically authorized to release all health care information relating to such diagnosis, testing or treatment.MANNER IN WHICH INFORMATION MAY BE DISCLOSED you are hereby authorized and requested to permit the examination of 3. above, and the copying or reproduction of same in any manner, whether mechanical, photographic, or otherwise, as requested by my attorney named above.
REVOCATION OF PRIOR AUTHORIZATIONS
I hereby revoke all medical authorizations, releases, disclosure authorizations, etc. provided to you for the release of medical information for any reason or purpose whatsoever, and given by me prior to the date signed below.
AUTHORIZATION AND DIRECTION TO FORWARD HEALTH CARE FACILITY BILLS I further authorize you to send copies of any and all bills to my attorney above named.
In the event of recovery by trial or settlement, I authorize my attorney to withhold an amount sufficient to cover these bills and to make payment directly to you and to deduct the amounts from any recovery that may be due me.
AUTHORIZATION TO ALLOW PHOTOGRAPHS TO BE TAKENI also authorize my attorney or their delegate to photograph my person while I am present in any health care facility.
EFFECT OF PHOTOCOPY OF DISCLOSURE FORM A copy of this disclosure form shall have the same force and effect as a signed original.
PERIOD OF VALIDITY OF DISCLOSURE AUTHORIZATION FORM This authorization form is effective on the date signed below and is valid without renewal unless and until revoked in writing by me.
___________________________ Patient's Signature
___________________________Social Security Number
___________________________Date of Birth