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Instructions for Completing
Patient Authorization to Disclose, Release or Obtain
Protected Health Information
Item #1 (Patient Information): The name, birthdate, phone number and Medical Record Number (if known) of the patient.
Item #2 (Purpose): indicate any and all purposes for disclosure.
Item #3 (Records to be released from): identify the holder of records to be released are for services provided.
Item #4 (Records to be disclosed to): identify the specific person(s) or class(es) of persons who are to receive the
information.
Item #5 (Information to be disclosed - All selections potentially include verbal communication about the records disclosed):
choose what information is permitted for disclosure.
• If “Images” box is used, specify type of images.
• The “VERBAL COMMUNICATION ONLY” option can be used to permit conversations with designated person(s)
identified in item #4.
• If “Other” box is used, description must be reasonably detailed.
Please be advised that you will be provided a copy of records that were requested and authorized as of the date of the
authorization These records will be generated from the Legal Health Record which in some instances involves a hybrid
record which may contain some paper as well as data and medical information and treatment records from multiple
Electronic health record systems. With the electronic health information being created and generated in real time by multiple
users we do our best to ensure the record provided to you contains all the documentation entered by the clinicians involved
in the patient’s care. If you should feel that you did not receive a complete set of the information requested please feel free
to reach out to the Health Information Department
Item #6 (Format for Records): indicate format desired. If both formats are needed, check both boxes.
Item #7 (Expiration): if “Other expiration event” is selected, the event must be one that is related to the patient (example termination of patient’s treatment, patient’s death) or to the purpose for the authorization (e.g., if the authorization is for
disability determination, the authorization might end when the determination has been finalized). Ordinarily, a specific date
is preferable.
Signatures:
In general, a patient age 18 or older has legal authority to sign this form. For patients younger than 18, generally the
patient’s parent or legal guardian must sign on behalf of the patient. There are many exceptions under Washington State
law to these general rules. (Examples – The patient is permitted to sign this form regardless of age for disclosures of patient
information related to reproductive health; If the patient is age 14 or older, the patient may authorize disclosure of HIV test
results; If the patient is age 13 or older, the patient may authorize disclosure of outpatient mental health treatment.)
For deceased patients, this form may be signed by the patient’s surviving spouse or personal representative.
All individuals signing for use or disclosure of medical information on behalf of a patient must state their relationship to the
patient and may be required to provide proof of legal authority to permit the use or disclosure of the medical information.
Note:
UW Medicine eCare (http://www.uwmedicineecare.org) is a free, secure and convenient way to access many different
types of personal health information in your inpatient or outpatient medical records. This information may include: Current
medicines, Allergies, Immunizations (vaccines), Medical history, Test results, Details of your previous clinic visits, Hospital
discharge instructions.