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, and Group Health medical record number of patient whose medical records are being requested.
2. Print name of organization or person that is being asked to release 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 one box 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; requests for a physician to complete forms; or other requests.
- Radiology images.
5. Check the box that applies to the reason the records are being requested.
6. Sign and indicate date signed.
7. 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, the minor must also sign the authorization.
8. Indicate date for the authorization to expire if it is to be different than 90 days from date of signing. (Note that if authorization is for disclosure to a financial institution or employer of a patient for purposes other than payment, the authorization will automatically expire 90 days after it is signed.)
9. 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).
10. Requests for imaging CDs (such as X-rays, MRI scans, or CT scans) 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 staff 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.
Once you have completed the form, you may mail it or drop it off at any Group Health Medical Centers location — in the business office or medical records department. See our medical facilities directory for the addresses and phone numbers of our clinics.
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 care 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. In addition, postage and sales tax may be charged. You may be sent an invoice or required to pay applicable fees prior to obtaining the copies. For example, if charges exceed $25, payment may be required in advance. Otherwise, payment is due upon receipt of your copies. Information disclosed pursuant to this authorization will not be redacted. Additional fees may apply if redaction is required.
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
Centralized Health Information Management
521 E Sprague Ave
Spokane, WA 99202
For imaging requests ONLY (X-rays, MRI scans, CT scans, etc.), contact:
Central Imaging Center
Capitol Hill Campus
Hours: 7:30 a.m.- 5:30 p.m.