PATIENT
AUTHORIZATION TO HEALTH CARE FACILITY FOR DISCLOSURE, ETC .
(Pursuant
to RCW 42.17 and RCW 70, Effective July 28, 1991)
TO: HEALTH CARE FACILITY of:
_______________________________________
_______________________________________
_______________________________________
Your patient, _____________________________, hereby authorizes you to
make the following disclosures:
1. DISCLOSURE TO BE MADE TO: my attorney, or any representative on
their behalf authorized in writing by said attorney, to wit: Injury At Sea, 4705 - 16th Avenue N.E.,
Seattle, Washington 98105, (206)527-8008.
In this regard, I waive any physician/patient privilege to my attorney
named above and at the address and telephone number also provided therein. Any future disclosure may be in writing
or in oral conversations at the option of my attorney. Your full cooperation with my attorney
is requested and appreciated.
2. DISCLOSURE NOT TO BE MADE TO: any other persons, including insurance
agents, insurance adjusters and other attorneys. If such request is made, please call my attorney named
above.
3. NATURE OF INFORMATION TO BE DISCLOSED: all health care information as defined
in Sec. 102 of the Uniform Health Care Information Act, restated herein as
follows: "...any information,
whether oral or recorded in any form or medium, that identifies or can readily
be associated with the identity of a patient and directly relates to the
patient's health care. The term includes any record of disclosures of health
care information."
4. SPECIFIC RELEASE: I understand that my express consent is required to
release any health care information relating to testing, diagnosis, and/or
treatment for HIV (AIDS virus), sexually transmitted diseases, psychiatric
disorders/mental health or drug and/or alcohol use. If I have been tested, diagnosed or treated for HIV (AIDS
virus), sexually transmitted diseases, psychiatric disorders/mental health or
drug and/or alcohol use, you are specifically authorized to release all health
care information relating to such diagnosis, testing or treatment.
5. MANNER IN WHICH INFORMATION MAY BE DISCLOSED: you are hereby authorized and requested
to permit the examination of 3. above, and the copying or reproduction of same
in any manner, whether mechanical, photographic, or otherwise, as requested by
my attorney named above.
6. REVOCATION OF PRIOR AUTHORIZATIONS: I hereby revoke all medical
authorizations, releases, disclosure authorizations, etc. provided to you for
the release of medical information for any reason or purpose whatsoever, and
given by me prior to the date signed below.
7. AUTHORIZATION AND DIRECTION TO FORWARD HEALTH CARE
FACILITY BILLS: I further authorize
you to send copies of any and all bills to my attorney above named. In the event of recovery by trial or
settlement, I authorize my attorney to withhold an amount sufficient to cover
these bills and to make payment directly to you and to deduct the amounts from
any recovery that may be due me.
8. AUTHORIZATION TO ALLOW PHOTOGRAPHS TO BE TAKEN: I also authorize my attorney or their
delegate to photograph my person while I am present in any health care
facility.
9. EFFECT OF PHOTOCOPY OF DISCLOSURE FORM: A copy of this disclosure form shall
have the same force and effect as a signed original.
10. PERIOD OF VALIDITY OF DISCLOSURE AUTHORIZATION FORM: This authorization
form is effective on the date signed below and is valid without renewal unless
and until revoked in writing by me.
DATED: __________________
___________________________
___________________________Social
Security Number
___________________________Date of
Birth
;