Authorization to Others to Release Confidential Information to Dr. Sterling

Please Print This Document, Fill it Out, and Send the Original to Dr. Sterling by Regular Mail

I, (print your full name)_______________________________________________________ , hereby authorize

__________________________________________________________
(Print Name of Provider or Institution releasing information)

__________________________________________________________
(Print Full Address of Provider or Institution releasing information)

__________________________________________________________
(Telephone No., Including Area Code, of Entity releasing information)

to release information in my medical/psychotherapy records. Only the following information may be released (please initial all that items you wish released):

  1. _____ Diagnosis.

  2. _____ Treatment information.

  3. _____ Medication information.

  4. _____ Summary of diagnosis, treatment and prognosis.

  5. _____ Photocopies of all medical records (A fee may be charged).

  6. _____ Other (please specify below).

    ___________________________________________________________

I understand that my express, written consent is required to release any health care information relating to testing, diagnosis, and/or treatment of HIV (AIDS), sexually transmitted diseases, psychiatric disorders or mental health problems, and drug, alcohol or other substance use or abuse. If I have been tested, diagnosed, and/or treated for HIV (AIDS), sexually transmitted diseases, psychiatric or mental health disorders, drug, alcohol or other substance abuse, I specifically authorize ___________________________________________________________ (print name of provider or institution releasing records) to release the following health care information relating to such diagnoses, testing or treatments (indicate which ones by initialing the appropriate items): _______ Information relating to treatment of HIV (AIDS) and sexually transmitted diseases; _______ Information relating to psychiatric disorders or mental health problems; _______ Information relating to drug, alcohol or other substance abuse.
I authorize ___________________________________________________________ (print name of provider or institution releasing records) to provide such information in the following manner(s) to the persons and/or organizations specified further below (please initial all forms of communication allowed):
  1. _____ By regular mail.

  2. _____ By telephone.

  3. _____ By Internet chat.

  4. _____ By e-mail.

  5. _____ By Fedex or courier. (A fee may be charged.)

  6. _____ By registered/certified mail, return receipt requested. (A fee may be charged.)

The information specified may only be released to the following person(s) and/or organization(s). Please print clearly the full name, full address, telephone number and e-mail address (if relevant) of said person(s) and/or organization(s).

    Ron Sterling, M.D., 12356 Northup Way, #100, Bellevue, WA 98005
    Phone: 206.784.7842

This released information may be used solely for health care treatment, insurance claim, or legal purposes. This authorization expires in 120 calendar days from the date on which the client signed it. It may be revoked at any time by written, signed, and delivered request.

___________________________________________________________
(Signature of client)

___________________________________________________________
(Social Security Number of client)

___________________________________________________________
(Date signed)

THIS FORM MUST BE SIGNED BY A WITNESS

___________________________________________________________
(Print name of Witness to client signature)

___________________________________________________________
(Relationship of Witness to client -- friend, sister, spouse, doctor, etc.)

___________________________________________________________
(Date signed)

___________________________________________________________
(Telephone Number or Address of Witness)

___________________________________________________________
(Signature of Witness)