Health Care Information Release Form Instructions

Follow these instructions when filling out the Authorization to Release Health Care Information form. Complete the form in ink. The second page is for Group Health to complete. (See Frequently Requested Forms.)

Form Sections

Patient information

Located on the top-right hand side of the form, below "Please Print."

• Print the patient's full, legal name.
• List any previous names, including maiden name.
• Print the birth date and Group Health member ID number, or Social Security number.
• List the patient's phone number.

Information to be released by

This section describes the organization that will release the patient's health care information.

• Print the organization's name (Group Health) or the doctor's name.
• Include the organization's complete mailing address.
• Print the office phone number.

Information to be released to

This section indicates the name of the person or organization that will receive the patient's health care information.

• Print the recipient's name, if necessary.
• Print the recipient's organization's name.
• Print the recipient's complete address.
• Print the recipient's office phone number.

Purpose of disclosure

Check one only. If "Other," please indicate the purpose. If you are authorizing a "verbal release of information" between your provider and another person, you must state this as your purpose.

General medical information

This section indicates the types of records being requested and the specific date range or treatment date.

• Check any box related to types of records being requested. If "Other," specify what information is being requested.
• Print the date.
• The patient or patient's authorized representative must sign (indicate relationship). A patient must be competent adult (18 years or older) or an emancipated minor (must show proof) to sign.
• Parents must sign for minors (17 years and younger) for general release. (See below for specially protected information.)
• An authorized representative, such as a legal representative for an incompetent patient, may sign for the patient. Provide a copy of legal documentation (for example, a Durable Power of Attorney).

Release requiring specific consent

• Initial the type of testing, diagnosis, or treatment to be released.
• Print the date.
• Sign where indicated, and include supporting documents (if applicable). To sign for himself or herself, the patient must be competent adult (18 years or older) or an emancipated minor (must show proof).
• Minor patients aged 13 to 17 years old must sign, depending on the category and age according to Washington state law (read the statement on the form).
• An authorized representative, such as a legal representative for an incompetent patient, may sign for the patient. However, the representative must provide a copy of legal documentation (for example, a Durable Power of Attorney).

Expiration date

List a date or event. If left blank, the authorization will expire 90 days after the signature date.

Completed Forms

The second page (or back side of the paper form) is for Group Health to complete.

Once you have completed the form, you may mail it or drop it off at any Group Health medical center's business office or medical records department. See our medical facilities directory for the addresses and phone numbers of our medical centers.