Health Care Information Release Form Instructions
Follow these instructions when filling out the Authorization to Disclose (Release) Health Care Information (PDF) form. Complete the form in ink.
The numbers refer to the sections on the form.
1. Print name of patient, birth date, Group Health consumer number, address, and daytime phone number for whom the medical records are being requested.
2. Check EITHER Group Health Cooperative if the records are located at Group Health or if located elsewhere, print the name of the physician, provider, or organization or person that is being asked to disclose copies of the records.
3. Print name, address, and phone number of organization or person that is to receive the copies of the information.
4. Check the box that applies to the reason the records are being requested.
5. Check boxes to indicate what information is to be disclosed:
- Information for most recent 2 years of visits.
- All inpatient, outpatient, and ambulatory surgery visits for the specific time frame indicated.
- All records related to the course of treatment, diagnosis, procedure, or condition indicated; form request, other.
- Billing records
- Radiology images (please specify specific information) for example “all breast imaging” or “8/17/15 MRI” or "ll head related 1990-
- Verbal communication only about your medical history or care. You can specify the specific information you would like
communicated using the Specific Information check box, otherwise you are agreeing that all your medical history can be
6. Read the patient authorization section.
7. Sign and indicate the date signed for patients ages 18 and older.
8. Minors between ages of 13 and 17 must authorize the release of certain information concerning the minor. If the information requested is concerning such a minor, 13-17: Chemical
Dependency, mental/psychiatric information; 14-17: HIV/Aids, sexually transmitted diseases, reproductive care.
9. Indicate date for the authorization to expire if it is to be different than 90 days from date of signing.
10. Patients/members may receive a paper copy or an electronic copy in an electronic format that is readily producible for records currently stored in electronic form. Electronic copies are currently available on compact disk or via Secure Delivery Portal (e-mail address required).
Requests for Imaging CDs (x-rays, MRI scans, CT scans etc.) are processed through the Digital Imaging Library at the Central Imaging Center. If you are ONLY requesting digital images, send your request to the Central Imaging Center or contact them at the number below. There is no charge if you are requesting that digital images be sent directly to a non-Group Health facility for your ongoing care.
Charges may vary for personal copies. If you have questions regarding charges, the imaging library staff can provide an estimate.
Group Health members can directly view and print some of their health information on this website after they register with MyGroupHealth for Members.
There is no charge for copying your medical records if you have the copies sent directly to a health care facility or provider for continuing or transfer of care. If you are requesting copies of medical records for yourself, you will get the first six pages free of charge. Additional pages will result in a copy fee being applied. Fees may be applied for portable electronic media supplied by Group Health.
In addition, postage and sales tax may be charged. You may be invoiced or required to pay applicable fees prior to obtaining the copies. Payment is otherwise due upon receipt of your copies. Information disclosed pursuant to this authorization will not be redacted. Additional fees may apply if redaction is required. Allow up to 15 days for processing your request.
Contact the appropriate department listed below to request your copies of your medical record, for information about copy charges and/or questions related to copying health information from your Group Health medical record.
Contact the appropriate department listed below to request your copies of your medical record, for information about copy charges, or questions related to copying health information from your Group Health medical record.
Centralized Release of Information
125 - 16th Ave E
Seattle, WA 98112
Phone: 206-326-3058 or 1-866-656-4184
Hours: 8 a.m. - 5 p.m.
Centralized Health Information Management
521 E Sprague Ave
Spokane, WA 99202
Hours: 8 a.m. - 5 p.m.
To request imaging CD/DVDs ONLY (X-rays, MRI scans, CT scans, mammograms, etc.), please send requests to:
Group Health Cooperative
Central Imaging Center