Authorization to Use/Disclose Health Care Information

Click to download and fill out the form to authorize the use/disclosure of your health care information:

Authorization To Use and Disclose Health Care Information

Release of Records May Take Up to 15 Working Days and International Community Health Services Will Only Process a Disclosure Request Based upon a Valid, Complete and Signed Authorization Form

Medical Records:

International Community Health Services is required by law to maintain the privacy of your health care information, to provide you with a notice of our legal duties and privacy practices, and to follow the information practices that are described in this Privacy Notice : Notice of Privacy Practices (available in six languages).

You have the right to receive a copy of your health care information that we maintain, with some limited exceptions. You may request access to your health care information in writing and you may request a copy of your health care information in electronic format. You have the right to request that your health care information be sent to any person or entity. Our Health Information Management department can help you obtain a copy of your medical records. To start the process, you may use the Authorization to Use/Disclose Health Care Information Form.

Where to Send Your Completed Form:

Mail or fax to the location where you received care:

International District Clinic PO Box 3007 Seattle, WA 98114 Attn: Medical Records Phone: (206) 788-3712 Fax: (206) 788-3706

Holly Park Clinic 3815 S. Othello Street 2 nd Fl Seattle, WA 98118 Attn: Medical Records Phone: (206) 788-3541 Fax: (206) 788-3521

Bellevue Clinic 1050 140th Ave. NE, Bellevue, WA 98005 Attn: Medical Records Phone: (425) 373-3012 Fax: (425) 373-3100

Shoreline Clinic 16549 Aurora Ave. N Shoreline, WA 98133 Attn: Medical Records Phone: (206) 533-2612 Fax: (206) 533-2641

Seattle World School Health Center 301 21st Ave East, Seattle, WA 98112 Attn: Medical Records/Dental Records Phone: (206) 971-0810 Fax: (206) 971-0842

Fee for Copying Medical Records:

For medical use, there is no charge if records are to be sent directly to a doctor or other healthcare provider for the purpose of continuing care.

For copies for personal or personal representative use, ICHS charges the following fees:

The first 10 pages are free.

11-200 = $ .39 per page, plus applicable sales tax

201 or more pages = $ .12 per page, plus applicable sales tax

The fee for copies on CD is $10

Postage: applicable amount if records are mailed.  You may request copies on paper, CD, or electronic/fax. When your record is copied and prepared for you, the copies and an invoice will be sent to you. Payment to ICHS is due upon receipt of your copies.

For copies for other uses, ICHS charges the following fees:

1-30 pages = $1.09 per page, plus applicable sales tax

31 or more pages = $ .82 per page, plus applicable sales tax

Clerical fee = $24 plus applicable sales tax.

RCW 70.02.010, WAC 246-08-400