Washington Medical Records Release Form 3Washington Medical Records Release Form 3
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AUTHORIZATION TO DISCLOSE
PROTECTED HEALTH INFORMATION
Olympic Memorial Hospital | Olympic Medical Physicians | Olympic Medical Home Health
PATIENT INFORMATION
Patient Name (printed):

Previous Name(s):

Date of Birth:
SEND INFORMATION TO: (please be specific)

Daytime Telephone Number:

Provider Name/Organization:
Address:
City:

State:

Phone #:

Zip:
Fax #:

INFORMATION TO BE RELEASED FROM: (please be specific)
Provider Name/Organization:
Address:
City:

State:

Phone #:
PURPOSE OF DISCLOSURE
 Transfer of Care

 Self

Zip:
Fax #:

 Specialist

 Other

(must complete)

INFORMATION TO BE DISCLOSED



Medical Records from last two years
Limited Health Information or Documentation
Complete Medical Chart Contents
Other

Dates of Service:
Expiration Date (or event)
(No more than 90 days forward)

CONSENT TO DISCLOSE

If the patient is unable to sign, please indicate such and the authority to act of the person who is signing for the
patient. This form must be dated within 90 days