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Claim No. <br /> 00,1`mg <br /> Ear Authorization forRelease of <br /> — Protected Health Information (PHI) <br /> To <br /> City of Everett <br /> July 2009 <br /> ...v.,n , r, .,a—.,}•..•.e.:...-ts..,w-...�;rC•'rP :. .., r. ,.:frr-z=.-..r..-: ;.rai ... .... ...- .,.•s. .,.. ._. -.;;—. .. ... <br /> Name: �51/Y1(4h, 1-61d.(/r(L Li i <br /> PLEASE PRINT(Last,First,Middle Initial or Middle Name) <br /> 1 i • <br /> Date of Birth: Month >�(k.(`A'N Day c ! Year j,1ep f <br /> • <br /> f <br /> i f <br /> I hereby authorize disclosure of my protected health information to the City of Everett(the"City"),including its adjusters, <br /> investigators and attorneys,for purposes of processing my claim for damages filed with the City. <br /> I understand that by signing this document,I authorize the release of the following information: <br /> Complete medical record for all services, Including history and physical exam; progress notes; x-ray <br /> reports; inpatient admissions; operative notes; physical or other` therapy; laboratory and other test <br /> reports; physician and physician assistant orders; nursing notes; and all other records and references <br /> designated by the provider as part of its medical record. <br /> i <br /> HIV Test Results and medical Information related to HIV testing or treatment. <br /> Psychiatric, mental and behavioral health records, including treatment notes, assessments, testing <br /> documents and results,and medical records related to mental healtl?diagnosis and treatment. <br /> I • <br /> Alcohol assessment,testing,referral or treatment records. <br /> All other chemical dependency assessment or treatment records. <br /> Pharmacy prescriptions and reports. <br /> All letters and memos received or sent, including electronic mail,referencing my treatment,information <br /> related to alleged sexual assault or sexually transmitted disease,including test results. <br /> Urgent care,outpatient or other clinic visit information. <br /> Gynecological and/or obstetrical information. <br /> I <br /> Ali client records generated for or by governmental programs that pay/paid for my health care. Identify <br /> the program(s)and agency: - <br /> i <br /> Financial records related to my care and treatment. <br /> ..•y•.... . .•,r•s-,.,,r.... •,. ...'..r...—..s,•r,sr:,,..-.. .l' . :•s'. . .t x: .. .. {i.:,`•-.:.<v.a� i-«:, ,•.;:.r...,._.. <br /> JJJJ� <br /> II/ <br />