Release of Information Form

To send a copy of your health record to another individual or agency, follow the instructions below.

• Download and complete the Release of Information form (here).
• To be valid, a FBH record request should:
  • Section 1 – Identify client with legal name, DOB, and phone number (FBH ID if you have it)
  • Section 2 – Identify the name of the agency and/or individual the information is to be disclosed to (Only one person per request)
    
  • Section 3 – Initial only 1 option. (If the individual is 12 years of age or younger, or the adult is a dependent, a parent, legal guardian or other representative is required to initial
    
  • Section 4 – Identify purpose of records request. Date range is not required.
    
  • Section 5 – Initial all line items you wish to disclose. (If the individual is 12 years of age or younger, or the adult is a dependent, a parent, legal guardian or other representative is required to initial.)
    
  • Section 6 – If applicable, please complete.
    
  • Section 7 – Identify only 1 option for expiration date or an expiration event that relates to the patient.
    
  • Section 8 – Please read.
    
  • Section 9 – Signature (legal name) and date of patient aged 13 and older.
    
  • Section 10 – Signature (legal name) and date (If the individual is 12 years of age or younger, or the adult is a dependent, a parent, legal guardian or other representative is required to sign).
    
  • Section 10 – Signature (legal name) and date (If the individual is 12 years of age or younger, or the adult is a dependent, a parent, legal guardian or other representative is required to sign).

Please allow sufficient processing time. Washington state law allows for a turnaround time of up to 15 business days. If you need assistance or have questions regarding the status of a request, please contact Medical Records at 509.458.7470.