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Northwest Spokane Pediatrics, PLLC - Better Business Bureau

Northwest Spokane Pediatrics, PLLC - Better Business Bureau 2025

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The document is an authorization form for disclosing or releasing health information from NWSP. It outlines the necessary patient identification details, the types of records that can be disclosed, and the reasons for disclosure. The form allows patients to grant permission for their confidential health records to be shared with specified individuals or organizations, while also detailing the rights of patients regarding their information and the limitations on further disclosure.

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Click ‘Get Form’ to open it in the editor.
Begin by filling out the 'Identification of Subject of Records' section. Enter the full name, date of birth, and any former names that may help locate records.
In the 'Patient Identification Number' field, provide any assigned identification number. Include other identifiers if necessary for accurate record retrieval.
Complete the 'Disclose To' section with the recipient's full name, title, organization, address, and contact information to ensure proper communication.
Select which records you authorize for disclosure by checking the appropriate boxes under 'Sources.' Be specific about what information you want shared.
If applicable, check any special consent records that need to be disclosed and specify limitations on the records if desired.
Sign and date the authorization at the bottom of the form. If signing on behalf of someone else, indicate your relationship and attach proof of authority.

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