Washington Medical Records Release Form 2Washington Medical Records Release Form 2
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INTERNAL USE ONLY:

Health Information Management
Fax: 425-339-5439 Phone: 425-339-5426

MRN: ________________________________
ROI Status:  Processed

 Returned to Requester  Encounter

 Chart Review  Return Letter Date: _________________
 Document(s) released in accordance with scope of patient request
Date records were provided: _________________

AUTHORIZATION FOR THE RELEASE OF MEDICAL INFORMATION
Please read all information and instructions before completing and signing the authorization form.
Patient’s Name ___________________________________________________________ Birth date _______________________
(Please Print)

LAST

FIRST

MI

Are medical records filed under another name? ____________________________ Phone Number _________________________
INFORMATION TO BE RELEASED BY:

 The Everett Clinic
 _____________________________________________
Organization/Person Name

INFORMATION TO BE RELEASED TO:

 The Everett Clinic
 _______________________________________________
Org