Records Requesting &/or Releasing Authorization

North Seattle Natural Medicine

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

Patient's First Name

Patient's Last Name

Alternative names (also goes by) OR Parent/Guardian's Name

Patient's Date of Birth

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.

Specify Records to Be Release (Ex; last 2 years)

Release Authorization / Request Please select ONE most appropriate option.

Authorization to Release NSNM Records

(send NSNM records to outside entity)

Requesting Records from other Clinics

(records to be sent to NSNM)

NAME OF Person/Doctor and/or Organization Records to be Released to OR Requested from.

Greatly appreciated if name of Doctor and/or Speciality is provided

PHONE NUMBER of Person/Doctor and/or Organization Records to be Released to OR Requested from.

FAX NUMBER of Person/Doctor and/or Organization Records to be Released to OR Requested from.

Signature (Full Legal Name)

By typing in my full legal name, I hereby acknowledge this acts as a written signature.

Today's Date

Signer's Email Address

Your information will be encrypted.