Records Release Authorization

Requests Will be Responded to Within 7 days

Please correct the errors described below.

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

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

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:

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

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.

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

Your information will be encrypted.