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

Claim No. ji/APH0 ,400(01 TT Authorization for Release of Protected Health Information (PHI) To City of Everett J ufy 2009 Name: Ran rn, .,_ ,.rs4-,k i, KP(Jtl PLEASE PRINT(Last, First, Middle initia"tor Middle Name) � Date of Birth: Month E P k.1/1(1\0Q _ f Day t Li , Year C.,,r P I hereby authorize disclosure of my protected health information to the City of Everett(the"City"),including its adjusters, investigators and attorneys,for purposes of processing my claim for damages filed with the City. I understand that by signing this document, I authorize the release of the following information: Complete medical record for all services, including history and physical exam; progress notes; x-ray reports; inpatient admissions;operative notes; physical or other therapy; laboratory and other test reports; physician and physician assistant orders; nursing notes; and all other records and references designated by the provider as part of its medical record. HIV Test Results and medical information related to HIV testing or treatment. Psychiatric, mental and behavioral health records, including treatment notes, assessments, testing documents and results,and medical records related to mental health diagnosis and treatment. Alcohol assessment,testing, referral or treatment records. All other chemical dependency assessment or treatment records. Pharmacy prescriptions and reports. All letters and memos received or sent, including electronic mail, referencing my treatment, information related to alleged sexual assault or sexually transmitted disease,including test results. Urgent care,outpatient or other clinic visit information. Gynecological and/or obstetrical information. All client records generated for or by governmental programs that pay/paid for my health care. Identify the program(s)and agency: 2DStS S 1 Financial records related to my care and treatment. C