Lynn Albertson Arnp, Ps 13110 Ne 177 Pl Ste B102 Woodinville Wa 98072 Phone: 425 415-8300

LYNN ALBERTSON ARNP, PS 13110 NE 177 PL STE B102 WOODINVILLE WA 98072 PHONE: 425 415-8300 FAX: 206 774-6450

AUTHORIZATION FOR DISCLOSURE OF MEDICAL RECORDS

PATIENT NAME: DATE OF BIRTH:

I AUTHORIZE AND REQUEST THE RELEASE OF RECORDS:

PROVIDER/Facility:

To Lynn Albertson ARNP, PS from: Address:

From Lynn Albertson ARNP, PS to: City/State/Zip:

Phone: Fax:

INFORMATION TO BE RELEASED:

Complete copy of all records  Immunization Records  Lab Reports (specify):

Health care information in my records pertaining to the following treatment/condition:

Other (please specify):

PURPOSE OR NEED FOR DISCLOSURE:

Continuation of medical care  Personal Request  Attorney Request  Insurance Request

Other:

MY RIGHTS:

I understand that information in my health record may include information relating to Sexually Transmitted Disease, HIV/AIDS or other communicable diseases, Behavioral Health Care/Psychiatric Care and treatment of alcohol and/or drug abuse; my signature authorizes release of any such information.

I may refuse to sign this authorization form. I understand that Lynn Albertson ARNP, PS will not condition or deny treatment on my signing this authorization.

I understand that I may revoke this authorization at any time, except to the extent that action based on this authorization has already been taken. A request for revocation must be made in writing and mailed to the address listed above.

Unless I revoke this authorization earlier, it will expire 90 days from the date signed or as specified:

I understand that, if this information is disclosed to a third party, the information may no longer be protected by state, federal regulations and may be re-disclosed by the person or organization that receives the information.

I release Lynn Albertson ARNP, PS, its employees and agents, medical staff members, and business associates from any legal responsibility or liability for the disclosure of the above information to the extent indicated and authorized herein. X SIGNATURE OF PATIENT or LEGAL REPRESENTATIVE RELATIONSHIP TO PATIENT DATE

RECORD RELEASE05132008