Instructions for the Public Health—Seattle & King County Authorization for Use and Disclosure of PHI form

Form completion instructions

Download the Authorization for Use and Disclosure of Protected Health Information (PHI) form (369 Kb)
This form is to request release of a PHSKC patient's Protected Health Information.

Autorización para el uso y revelación de información protegida de salud (Español / Spanish, 566 Kb)

• "Information": means Protected Health Information (information that identifies a patient).
• "I authorize this patient’s information to be released"*: Write in the patient’s name, date of birth, and any other name(s) the patient is known as.
• "Release information from"*: Choose or write in the location the information is from (for example choose "Public Health Clinic (write in clinic)" and write in "Kent Public Health Center").
• "Release information to"*: Write in who you want the information to go to, and their contact information.
• "Information Dates or Date Range"*: Write in the service dates you are requesting information about.
• "Information Types"*: Choose what information you want released.
  • All choices include verbal communication about records.
  • If you only want information released verbally, please choose only "Verbally Release Information".
  • When requesting King County Medic One records: you must write in the address or cross street where the King County Medic One care was provided, and time and date the care was provided. There are specific lines for you to write in this information. Note: Medic One does not bill for services. Therefore, Medic One does not have billing records.
• "Purpose of Release": Choose what the reason is for the release.
• "Do NOT include the following information": Choose the information you want excluded (redacted) from release.
• "This authorization expires on this date or event": The authorization expires one year from the date it is signed unless you write in another expiration date or event. If you write in an event and it is unclear to PHSKC if the event has occurred, PHSKC will assume the authorization expires one year from the date it is signed.
• "Patient or Authorized Adult Signature"*: An Authorized Adult is a person aged 18 or older who is legally authorized to act on the patient’s behalf in making health care related decisions. The Form must be signed by the patient or an Authorized Adult.
• "Print Name and Relationship to Patient, if signed by person other than patient"*: Anyone signing the Form as an Authorized Adult must also print their name and the relationship that legally authorizes them to act on the patient’s behalf in making health care related decisions (such as, "parent" or "legal guardian").

* If the patient or authorized adult is asking to access or get a copy of the patient’s records for themself or to give to a third party: only the asterisked sections are required.

Where to send the form

• Public Health Center Requests: please mail, fax, or bring in the form to the Public Health Center (clinic) you are requesting records from.
• Jail Health Services Requests:  please fax Form to 206-296-1771.  If you do not have access to a fax machine, please send by
  • Email to: JHSRequests@kingcounty.gov
  • Mail to:
    Health Information Management
    Jail Health Services
    500 5th Avenue, Mailstop: KCF-PH-0600
    Seattle, WA 98104
    
• King County Sexual Health Clinic Requests, please fax the form to 206-744-8771.  If you do not have access to a fax machine, please mail to:
  
  • King County Sexual Health Clinic
    325 9th Ave, Box 359777
    Seattle, WA 98104
• Tuberculosis (TB) Control Program Requests, please fax the form to 206-744-4350.  If you do not have access to a fax machine, please mail to:
  • King County TB Control Program
    325 9th Ave, Box 359776
    Seattle, WA 98104
• Medic One Requests, please fax the form to 206-296-0515.  If you do not have access to a fax machine, please mail to:
  • King County Medic One
    20811 84th Ave S., Suite 102
    Kent, WA 98032
• All other requests, please send the form to the PHSKC central medical records release team by:
  • Email to: DPHROIHotline@kingcounty.gov
  • Mail to:
    Health Information Management
    Public Health—Seattle & King County
    401 5th Ave, Suite 1220
    Seattle, WA 98104-1818
    or,
  • Calling the PHSKC central medical records release team at 206-263-9700 to make other arrangements

Cost, payment and invoicing

• PHSKC provides a free record set to:
  • Person signing the Form (Patient or Authorized Adult).
  • Patient’s family member; and
  • Attorneys representing patients appealing the denial of federal Supplemental Security Income or Social Security Disability Insurance benefits.
• Cost for all other requestors:  $6.50 per record set.
  • Payment method: Check made payable to Seattle-King County Dept. of Public Health.  Send check to:
    Health Information Management
    Public Health—Seattle & King County
    401 5th Avenue, Suite 1220
    Seattle, WA 98104-1818
• Invoicing:  PHSKC sends invoices via email, fax, or US Mail when records are ready.
• For records releases to King County staff, PHSKC sends invoice to requestor and then releases records to requestor within 2 business days of sending invoice. 
• For records releases to requestors other than King County staff, PHSKC sends invoice to requestor, and then sends records once PHSKC receives payment.

Records format

We will assume you want records mailed to you in Compact Disc (CD) format unless you are incarcerated in a King County jail. If you are incarcerated in a King County jail we will assume you want paper records. If you want records in a different format, please send a note with the Form stating the desired format or contact us by phone or email to make other arrangements. Format options include CD, paper, email, reviewing the records in person, or other manner as agreed to by PHSKC and requestor.