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35) Medical Records Request From

Medical Records Request From Home Towne

Enter Name, Address and Phone number to the person or entity you wish to receive your records.

Information sent from : Home Towne Family Medicine. 15580 3rd AVE SW, Suite 101, Burien, WA 98166

I understand that my records may contain information regarding the diagnosis or treatment of HIV/AIDS, sexually transmitted diseases, drug and/or alcohol abuse, mental illness, or psychiatric treatment. I give my specific authorization for these records to be released.

I understand I do not have to sign this authorization in order to obtain health care benefits (treatment, payment or enrollment). I may revoke this authorization in writing. To view the process for revoking this authorization, please read the Privacy Notice to Patients posted at the facility where your information is being released. I understand that once the health information I have authorized to be disclosed reaches the noted recipient, that person or organization may re-disclose it, at which time it may no longer be protected under Privacy laws.

This authorization will expire 90 day from the date signed. Possible copying fee may be required.
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