If both boxes are checked, CHAS Health staff will release records as specified and send the information to the location listed.
Medical Records Release Form
CHAS Health · Attn: Health Records 611 N. Iron Bridge Way, Spokane, WA 99202 · Phone: 509.434.0381 · Fax: 509.434.0392
Authorization for CHAS Health to Obtain or Disclose My Health Care Information (*Required)
*Patient Name:________________________________________________ Previous Name:_______________________________________________ Date Records Needed By:______________________________________
*Date of Birth:________________________________ *Daytime Phone:______________________________
*If both boxes are checked, CHAS Health staff will release records as specified and send the information to the location listed. I request and authorize CHAS Health to: o Release To o Obtain From via (choose one) o Email o Fax o Mail
Name:________________________________________________________ Address:______________________________________________________ City:_________________________________________________________ State:_______________________ Zip Code:______________________
Email:______________________________________ Fax:________________________________________ Phone:_____________________________________
*You may use or disclose the following health care information (mark all that apply): o Verbal Only o Records Only o Verbal and Records o Appointment Info Only
Types of Information to Release:
o Billing Records
o Imaging/Diagnostic Reports
o Medication List
o Chart Notes
o Immunizations
o OB Records
o Dental: ___ Records ___ X-rays
o Lab and Pathology Reports
o Other_____________________________
o All health care information (excluding sensitive information listed see below) for the last 2 years, unless specified.
I understand that my medical record may include information on a diagnosis/treatment related to psychiatric, psychological or mental conditions, drug and or alcohol use or abuse, sexually transmitted infections (STI), acquired immune deficiency syndrome (AIDS), and or HIV status and genetic testing.
I consent for the following information to be disclosed: (mark any/all that apply):
o Drug and/or alcohol use
o Psychiatric disorder/mental health
o HIV (AIDS virus)
o Sexually transmitted infections
*Reason for Authorization: o At the request of the individual; o Other________________________________________________
*Expiration: o Date:________/______/________ OR o Event (one time release):________________________________________
If date is not specified, this request will expire in 90 days from the date of signature. If the release is for the patient's EMPLOYER or FINANCIAL INSTITUTION for reasons other than payment, this authorization will remain valid for only 90 days. Patient may revoke this authorization at any time prior to expiration by notifying CHAS in writing.
The information disclosed pursuant to this authorization may be subject to redisclosure and no longer protected by federal law. State and federal law specifically requires that any patient medical record and/or personal health care information containing drug and alcohol diagnosis and treatment, mental health and sexually transmitted infections, including HIV/AIDS are privileged and confidential and may only be disclosed by express authorization, except as required by law. I understand that my alcohol and/or drug treatment records are protected under the Federal regulations governing Confidentiality and Drug abuse Patient Records, 42 CFR Part 2 and Health Insurance Portability and Accountability Act of 1996 ("HIPAA"), 45 CFR pts 160 & 164, and cannot be disclosed without my written consent unless otherwise provided for by the regulations.
I understand that I may refuse to sign this authorization. CHAS may not condition treatment, payment, enrollment or eligibility on the authorization of this release. Electronic Signatures. This Medical Records Release form (Agreement) is, and related documents entered into in connection with this Agreement are, deemed signed when a party's signature is delivered electronically. The signor is executing this Agreement electronically and intends to be bound by the Agreement and agrees that the electronic signature shall be deemed original signatures having the same legal effect as original signatures to the fullest extent permitted by applicable law, including the Federal Electronic Signatures in Global and National Commerce Act, and any similar state law based on the Uniform Electronic Transactions Act, and the parties hereby waive any objection to the contrary. The signor acknowledges that this term is hereby incorporated into the Agreement.
*Signature/Legally Responsible Party
Relationship to Patient
*Date
A minor's signature alone is sufficient to release health care information related to (1) sexually transmitted diseases, including HIV/AIDS (age 14+), (2) alcohol and/ or drug abuse (age 13+ (Idaho is 16+)), (3) mental health information (age 13+ (Idaho is 14+)), (4) birth control services ( WA only), (5) abortion services (WA only), and (6) prenatal care services (WA only).
Signature of Minor Patient
Date
Revised 8/25/2020 CHAS_08-016-20
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