Records Release Authorization

Emergency Assistance

If this is an emergency, call:

Crisis Line: (866) 425-4747
911

Office Releasing Records:
Dr.Trina Seligman
8201 164th St, Suite 200, Redmond, WA 98052
Ph: 425-999-4503 Fax: 425-646-4770

Patient Name

Date of Birth

Release to:

Myself Office//Physician

Your records will be sent to the email associated with your Patient Fusion account.

Office/Physician receiving the records:

Street, City, Zip

Phone

Fax:

I authorize the following release of information from my patient records:

Chart Notes

Operative

Lab / Pathology

Radiology

Other (please specify):

Date of Information to be Released

Last Visit

6 Months

12 Months

Specify other dates:

Sensitive records may require specific patient authorization. Please check the applicable box below to request the following records:

Mental Health

Sexually Transmitted Infections

AIDS / HIV Treatment

Substance Abuse Treatment

I understand that:

Authorizing the disclosure of this healthcare information is voluntary. I do not need to sign this form in order to assure treament or payment.
I can cancel this authorization at any time by communication in writing to Evergreen Integrative Medicine. I understand that once the information has been released, the information cannot be recalled.
Any disclosure of information carries with it the potential for further release or distribution by the recipient that may not be protected by confidentiality laws.

This authorization will expire 90 days from the date signed below unless another date is provided here:

Date of Expiry (if not 90 days):

Sign and Submit

Your signature is required to complete this document and initiate records transfer. If you have questions or concerns with any policy or part of this document please contact our office by email at staff@eimed.com.

My typed signature below is an indication that I authorize the transfer of records as indicated and have reviewed and agree with all policies presented.

Patient Signature (typed):

Date

Guardian Signature (If Patient is a minor):

Date

I understand that typing in my full legal name on this form substitutes as a written signature.

Print this form if you require a copy for your personal records.

Your information will be encrypted.

Dr. Trina Seligman

Naturopathic Doctor

Dr. Trina Seligman graduated with a Doctorate in Naturopathic Medicine in 1996, and a Masters in Acupuncture in 1999. Dr. Seligman opened her practice with the goal of integrating natural medicine with conventional therapies. She has worked diligently to stay on top of research in natural medicine and to provide her patients with the highest quality of integrative care. Her practice is a family practice with an interest in women’s health, mental health and gastrointestinal diseases. Trina was diagnosed with Ulcerative Colitis as a teenager and has always hoped to integrate conventional medicine with natural medicine to help provide IBD patients with better choices and a more comprehensive treatment plan. When developing a treatment plan, she likes to take a collaborative approach, not only with the patient, but blending the best of both conventional and natural medicines. She uses bio-identical hormones, herbal and nutritional therapies and enjoys talking about lifestyle and exercise.

425-999-4503
www.DrTrinaSeligman.com