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Below you will find many authorizations and forms required to retrieve records
throughout the Northwest, as well as from several government agencies. All of
these forms can be printed or saved into your directory for future use. I like
to keep my friends current on forms, so if you have one you would like posted
or need a form and can't find it, please email us at
Contact@medrecs.com. We will just keep adding to the list.
Medrecs Record Request Form
MEDICAL AUTHORIZATIONS
General Release of Information Authorization which contains content and wording
for the release of sensitive information which may be covered by state and
federal statutes.
Authorization for
Medical Records of Dependants of Military Personel
Deaconess Hospital -
Spokane, WA
Authorization to release health care information.
Harborview Medical
Center
Authorization for release of medical records from Harborview Medical Center -
Seattle, WA.
Kaiser Permanente Release of
Medical Information
Authorization for any Kaiser Permanente location within Washington or Oregon.
Langley
Memorial Hospital
Authorization for release of information - Langley, British Columbia.
Authorization must be witnessed.
Memorial Clinic
Authorization for medical records from Memorial Clinic - Olympia, WA
Oregon State Authorization to
Release Health Care information
Authorization which contains specific content and wording required by Oregon
law.
Swedish Medical Center
- All Campuses
Authorization for release of health information from Swedish Medical Center
(Main, Providence, and Ballard Campuses)
University of Washington Medical
Center
Authorization for release of medical records from the University of Washington
Medical Center - Seattle, WA.
Valley Medical Center
Authorization for release of medical records from Valley Medical Center -
Renton, WA.
GOVERNMENTAL AUTHORIZATIONS
Internal Revenue
Service Request for Copy or Transcript of Tax Form
IRS (Form 4506) release for tax records. Information from the IRS can be
obtained for the last 7 years, excluding the current year. Please note the IRS
requires an original signature and prepayment for records. Additionally, normal
response time for these types of records can be 2-4 months.
Request Pertaining to Military Records:
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Authorization required by national military archive centers for the release of
military files which include both medical and service records. Please note an
original signature is required.
Social Security
Earnings Information Form
Authorization (form 7050) for the release of detailed earnings information from
the Social Security office in Baltimore. Please note the Social Security office
requires an original signature and prepayment for records. Additionally, normal
response time for these types of records can be 4-6 months.
Social Security Consent for Release of Information:
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Authorization (form 3288) for the release of the claimant's disability claim
file. Active files are normally held at a local Social Security Disability
office or the appropriate hearings office. If the claim has been closed the
file is generally ordered from Baltimore.
MISCELLANEOUS FORMS
Declaration of
Custodian of Records
Washington State
Patrol Public Record Disclosure Request
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