Patient Information
Disclosing & Receiving Providers
Records & Purpose
I authorize release of the following records relating to evaluation and treatment between January 12, 2024 and the present date. Only items marked below will be disclosed.
Patient Rights & Terms
Right to Revoke. I understand that I may revoke this authorization at any time by submitting written notice to the Pacific Medical Center Health Information Management office, except to the extent that action has already been taken in reliance upon it.
Expiration. Unless revoked earlier, this authorization will expire one hundred eighty (180) days from the date of signature, or upon completion of the stated purpose, whichever occurs first.
Redisclosure. I acknowledge that information released pursuant to this authorization may be subject to redisclosure by the recipient and may no longer be protected by federal privacy regulations under HIPAA.
Conditions. Treatment, payment, enrollment, or eligibility for benefits at Pacific Medical Center will not be conditioned upon whether I sign this authorization, except where permitted by 45 CFR §164.508(b)(4).
Fees. A reasonable cost-based fee may apply for copies of records, consistent with applicable Washington State regulations.
Copy. I understand I am entitled to receive a signed copy of this authorization for my personal records upon request.