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  Medical Release Authorization  We are committed to serving the Transgender Community
You only need to provide the information for your specific need. We do not need your entire medical history. We only need to work with your provider to assist you. Do Not fill out this form, until requested to do so. Seattle Transgender Help Network
701 Fifth Avenue Suite: 4200 Seattle, Washington 98104-5119
P: (206) 262-7580, F: (206) 262-8001
lnfo@SeattleTransgender.org
I HEREBY GIVE AUTHORIZATION TO USE OR DISCLOSE MEDICAL OR MENTAL HEALTH CARE INFORMATION, TO SEATTLE TRANSGENDER HELP NETWORK.
* Required Field Patient Name:*____________________________________________ MRN*: _____________
PCP:*___________________ . Social Security*_________________ . Birthdate: *________
This is to authorize information specified below to be released by:
Health Care Provider:* ________________________________________________________
Address:* _____________________________________________________________________ City:*_____________________________ State:*____________________ Zip:*_____________ Phone:*(___) ____ -_________ . Fax:*(___) ____-_________ . E-mail: *__________________
And sent to: Seattle Transgender Help Network
Department of Essential Health Care Program.
701 Fifth Avenue Suite: 4200 Seattle, Washington 98104-5119
_______________________________________________________________________________
_________________________INFORMATION TO BE DISCLOSED________________________
Summary of Medical History/Treatment for the last two years will be released, unless otherwise specified.
I specifically authorize any information in the subject areas checked below to be released* (complete records will not be sent unless purpose clearly demonstrates need).
[ ] Laboratory/ Diagnostic tests. [ ] Mental Health Illness, Treatment, and/or Assessment.
[ ] Sexually transmitted diseases. [ ] Drug and/for Alcohol Treatment.
[ ] HIV/AIDS (infection and/or antibody status)
[ ] Other (please specify): __________________________________________________________
Purpose or need for data (MUST BECOMPLETED): *____________________________________
I understand I do not have to sign this authorization in order to get health care. This authorization may be revoked at any time unless action has already been taken, or 90 days from the date signed, or when the following event occurs:
Once health care information is disclosed, the person or organization that received it may re-disclose it. Privacy laws may no longer protect it. Signature:* ___________________________________________ESCA. Date: * ______________ (patient/parent/guardian/representative) Please copy & paste this page in your e-mail. Security of Your Personal Information Seattle Transgender Help Network is committed to protecting the security of your personal information. We use a variety of security technologies and procedures to help protect your personal information from unauthorized access, use, or disclosure. For example, we store the personal information you provide on computer systems with limited access, which are located in controlled facilities. When we transmit highly confidential information (such as a credit card number or password) over the Internet, we protect it through the use of encryption, such as the Secure Socket Layer (SSL) protocol. Copyright © 2006-2007 The STHN Group Last modified March 21, 2007 |
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