1111 47TH ST SE 2022-05-31 - Laserfiche WebLink

Authorization for Release of Protected Health Information(PHI)to City of Everett Page 2 I understand the following: (Please read and initial all statements) R- k I understand that my records are protected under HIPAA/PHI regulations(federal law)and the Washington State (Initia.l) Health Care Information Act(RCW 70.02). 12-k I understand that my health information may be subject to re-disclosure by the City and not protected (Initial) for purposes of evaluating and investigating the claims have filed with the City. i2 k I understand that the specific information to be disclosed in my medical record may include information regarding (Initial) alcohol, drug or other controlled substance use,counseling referrals and/or a history of testing or treatment of acquired immune deficiency syndrome. (2..tG I understand that I may revoke this authorization at any time by notifying the City of Everett in writing,and that (Initial) the revocation will be effective as of the date the City receives it. Any records obtained pursuant to this Authorization for Release of PHI prior to the revocation will be deemed authorized by me for release. 1Z.K _ I understand that this Authorization for Release will be valid until my claim is resolved or closed by the City. (Initial) A copy of this Authorization carries the same authority as the original for purposes of releasing my records to the City. Signature of Authorizing Individual: Re J ! i Date of Signature: 7._ 11 1, ! Telephone Number: l 14 25) 3c2 7 6 75c-/ Witness(where patient is over 13 and signing the release): Where the signer is not the subject of the records: I am authorized to sign this because I am the(attach proof of authority): ❑ Parent of Minor - ❑ Legal Guardian ❑ Personal Representative ' ❑ Other To the Provider or Records Custodian: Please send legible copies of all records to: City of Everett c/o Legal Department 2930 Wetmore Ave,Suite 10-C Everett,WA 98201