Records Requesting &/or Releasing Authorization

For releasing or securing confidential healthcare records.

Please correct the errors described below.

North Seattle Natural Medicine

617 5th Ave S
Edmonds, WA 98020
Phone: (206) 629-5180
Fax: (206) 629-5197
HIPAA Secure Email:

Who are you releasing records to/from?

TO RELEASE the following information contained in the patient’s medical records.
I understand that my express consent is required to release any health care information relating to testing, diagnosis, and /or treatment.
With regard to HIV, sexually transmitted diseases, psychiatric disorders/mental health, and drug or alcohol use, you are specifically authorized to release all health care information pertaining to such diagnosis, testing , or treatment.

Greatly appreciated if name of Doctor and/or Speciality is provided
By typing in my full legal name, I hereby acknowledge this acts as a written signature.

Your information will be encrypted.