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Authorization obtain patient information form

Release obtain information 2026

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The document is an authorization form for patients to release, obtain, or exchange their health information from Seattle Children's Hospital. It includes sections for patient identification, recipient details, purpose of the request, and specific types of records to be released. The form outlines the patient's rights regarding the release of information, including voluntary signing and potential redisclosure risks. It also specifies requirements for minors' consent for certain sensitive information and provides instructions for completing and submitting the form.

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Click ‘Get Form’ to open it in the editor.
Begin by entering the Patient Name, Date of Birth, and any Other Names Used. Ensure accuracy as this information is crucial for identification.
Fill in the Medical Record Number if applicable, and select whether you wish to Obtain From or Release To a specific organization or recipient.
Provide the Organization/Recipient's name, address, phone number, and email (if applicable) for electronic delivery.
Indicate the purpose of your request by checking the appropriate boxes such as Continuing Care or Personal Use.
Specify the records you wish to release by indicating the dates and types of records needed. If no date range is specified, an abstract will be sent.
Review the Notices section carefully to understand your rights regarding this authorization before signing.
Finally, sign and date the form. If applicable, ensure a minor patient’s signature is included for specific consent.

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