Stanwood, WA · Snohomish County
Authorization for Disclosure of Health Care Information
This authorization lets a patient or legally authorized individual permit health care information to be disclosed to the Stanwood Police Department for a stated reason.
What this form is
The form authorizes disclosure of health care information to the Stanwood Police Department and provides space to identify the patient, the records requested, and the reason for the authorization. It includes a section for a criminal investigation, an expiration selection limited to 90 days from signing, and statements about the signer’s rights. The form also has signature and date lines for the patient or authorized individual, a witness, and a law enforcement agency.
Who needs it
A patient or legally authorized individual may use this form to authorize disclosure of health care information to the Stanwood Police Department.
How to submit it
The form names the Stanwood Police Department as the recipient at PO Box 127, Stanwood, WA 98292, or by fax at 360-629-2886; it does not specify how to submit the authorization.
About notarization
This document is signed without a notary; the patient or legally authorized individual signs and dates it, and it also provides lines for a witness and law enforcement agency.
How to submit this form
- 1
Download The Form
Download the Authorization for Disclosure of Health Care Information PDF.
- 2
Complete The Patient Information
Enter the patient’s name, date of birth, previous name(s), and the requested health care information.
- 3
State The Reason And Expiration
Complete the reason for authorization and select an expiration that is no longer than 90 days from the date signed.
- 4
Sign And Date
The patient or legally authorized individual signs and dates the form; the form also provides witness and law enforcement agency lines.
- 5
Use The Listed Recipient Details
The form names the Stanwood Police Department at PO Box 127, Stanwood, WA 98292, or by fax at 360-629-2886.
Frequently asked questions
- What does the Stanwood health care disclosure authorization do?
- It authorizes disclosure of health care information to the Stanwood Police Department and includes space to state the reason for the authorization.
- Who can sign this authorization?
- The form provides signature lines for the patient or a legally authorized individual, as well as a witness and law enforcement agency.
- Do I need a notary for the health care disclosure authorization?
- No. This document is signed without a notary; the patient or legally authorized individual signs and dates it, with separate lines for a witness and law enforcement agency.
- How do I submit the health care disclosure authorization?
- The form lists the Stanwood Police Department as the recipient at PO Box 127, Stanwood, WA 98292, or by fax at 360-629-2886. It does not specify how to submit the authorization.