Bellingham Health
1050 Larrabee Ave, Ste 204, Bellingham, WA 98225
Phone (360) 756-9793, Fax (360) 752-9007


Patient Name (print): _____________________________________________________

Date of Birth: ___________________________________________________________

By signing this Authorization Form (“Authorization”), I understand that I am giving my authorization to Bellingham Health, located at 1050 Larrabee Ave, Ste 204, Bellingham WA 98225, its employees, designees, agents, independent contractors, legal representatives, successors, and assigns (“Practice”) to use and/or disclose my protected health information as described in more detail in the paragraphs below, to the following person(s) or organization(s):

Name of person(s) or organization(s): _______________________________________________
Street address: ________________________________________________________
City, State, and Zip Code: ________________________________________________
Telephone number: _____________________________________________________
Facsimile number: _____________________________________________________

I specifically authorize the use and disclosure of the following PHI:
(Please provide a detailed description of the particular data and period of time you are requesting): _____________________________________________________________________________

If this authorization is for any purpose other than the release of medical records for personal reasons, please state the purpose of the authorization to release PHI below: 

Right to Revoke: I have the right to revoke this authorization at any time by providing written notice of my revocation to the contact person listed below:

                      Bellingham Health
                     Attn: Bonnie Sprague

Please understand that revocation of this Authorization will not affect any action Practice took in reliance on this Authorization before receiving my revocation.

Unless earlier revoked, this Authorization will expire 60 days after patient signature date below.

I hereby hold harmless and release Practice from all claims, demands and causes of action which I, my heirs, representatives, executors, administrators or any other persons acting on my behalf or on behalf of my estate have or may have by reason of this Authorization.

If neither federal nor state privacy laws apply to the recipient of the information, I understand that the information disclosed pursuant to this authorization may be re-disclosed by the recipient and no longer protected by federal or state privacy law.

I may inspect and receive a copy of the information to be used and disclosed pursuant to this Authorization form.

This Authorization is voluntary and I may refuse to sign this Authorization form.

If I am providing authorization for marketing purposes, I understand that Practice may receive remuneration from a properly authorized business associate as a result of using or disclosing the my protected health information.

I understand that my refusal to sign this Authorization will have no effect on the medical treatment I receive from Practice.

______________________________________________________           ___________________
Signature of Patient                                                                Date

______________________________________________________           ___________________
Signature of Patient’s Representative (if applicable)              Date

Printed name of Patient’s Representative (if applicable)

Relationship to patient (if applicable)


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