Health Care Information Release Form Instructions
Follow these instructions when filling out the Authorization to Disclose (Release) Health Care Information (PDF) form. Complete the form in ink.
The numbers refer to the sections on the form.
1. Print name of patient, birth date and Group Health medical record number of patient whose medical records are being requested.
2. Print name of organization or person that is being asked to release copies of the records.
3. Print name, address, and phone number of organization or person that is to receive the copies of the information.
4. Check one box to indicate what information is to be disclosed:
5. Check the box that applies to the reason the records are being requested.
6. Sign and indicate date signed.
7. Minors between ages of 13 and 17 must authorize the release of certain information concerning the minor. If the information requested is concerning such a minor, the minor must also sign the authorization.
8. Indicate date for the authorization to expire if it is to be different than 90 days from date of signing. (Note that if authorization is for disclosure to a financial institution or employer of a patient for purposes other than payment, the authorization will automatically expire 90 days after it is signed.)
Once you have completed the form, you may mail it or drop it off at any Group Health Medical Centers location in the business office or medical records department. See our medical facilities directory for the addresses and phone numbers of our clinics.
There is no charge for copying your medical records if you have the copies sent directly to a health care facility or provider for continuing care or transfer of care.
If you are requesting copies of medical records for yourself, you will get the first six pages free of charge. Additional pages will result in a copy fee being applied. In addition, postage and sales tax may be charged. You may be sent an invoice or required to pay applicable fees prior to obtaining the copies. For example, if charges exceed $25, payment may be required in advance. Otherwise, payment is due upon receipt of your copies. Information disclosed pursuant to this authorization will not be redacted. Additional fees may apply if redaction is required.
Contact the appropriate department listed below to request your copies of your medical record, for information about copy charges, or questions related to copying health information from your Group Health medical record.
Access Your Online Record
If you get care at a Group Health Medical Centers clinic, you can get access to your online medical record by registering with MyGroupHealth for Members. You also can request access to your children's online records.
Your online record doesn't include certain hospital records, Behavioral Health records, or care you have gotten from providers who don't work at a Group Health facility. You may request a copy of those records by following the instructions in the center column.