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Authorization to Release Patient Health Information

  1. I authorize Eastside Fire and Rescue (EF&R) to release information as stated below:

  2. Information To Be Released To:

  3. Information To Be Released:

  4. Information Requested

  5. Preferred Format (Check Only One)

    Please note if a format is not selected, records will be in paper format.

  6. Authorization for Release of Information

    I understand that authorizing the disclosure of this healthcare information is voluntary. I can cancel this authorization at any time by writing to EF&R. I understand that once the information has been released according to the terms of this authorization, the information cannot be recalled. Any disclosure of information carries with it the potential for further release or distribution by the recipient that may not be protected by confidentiality laws. This authorization will expire 90 days from the date signed below unless another date or event is entered here:

  7. Note: If the disclosure is to an employer or financial institution, this authorization will expire 90 days from the date signed by you.)

  8. Signature of Patient / Legal Representative

  9. Requesting Medical Records on Behalf of Another Person

    If you are requesting medical records for someone other than yourself, you may be required to provide additional documentation to show that you have a legal right to request the record set. Examples of these documents include Letters of Representation, Guardianship Papers, Affidavits of Heir at Law, etc.

  10. Sending Instructions

    You can submit this form or print it and send the completed form and any attachments via email to records@esf-r.org, fax to 425-313-3237, or mail to the following address:

    Eastside Fire and Rescue
    175 Newport Way NW
    Issaquah, WA 98027

  11. Leave This Blank:

  12. This field is not part of the form submission.