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*SHIM007*
HIM007 (12/19)
(staff may use patient label below) SCCA Medical Records Request (1 of 2)
Patient name (last name, first name):
Date of birth or medical record number (U#):
1. I give permission for SCCA to: (check only one):
អ Talk to my family, friends or អ Give my medical records to an អ Gather my medical records
others about my care outside facility/person/me from an outside facility/person
Fill in this chart for the above request
Person/facility
List physician(s), family
member(s), friend(s), etc.
Phone number Other contact information
List address, email and/or fax #
How would you like info
released?
Mail, email, fax, verbal, other?
Signature (patient or authorized representative): Print name Date (mm/dd/yyyy)
If signed by person other than patient, provide relationship to patient and description of authority:
2. Please let us know why you’re requesting this information:
អ Health care អ Personal អ Insurance អ Legal អ Other
provider
3. Type of records (check all that apply):
អ Clinic notes អ Lab/pathology អ Radiology reports អ Imaging CD អ Other
reports South Lake Union clinic only
4. Records within the following dates (check one)
អ Records between (write dates in mm/dd/yyyy) _____/_____/_____ and _____/_____/_____
អ All of my records since the beginning of treatment
5. Expiration date
This form is only good for 90 days from the date you sign it unless you fill out the information below.
Stop sharing or getting my information:
អ When I finish my treatment at SCCA អ On this date: _____/_____/_____ អ Other:
6. Regarding sensitive information
Adults: I understand that the information in my health record may include sensitive information related to HIV/AIDS,
sexually transmitted infections, behavioral or mental health services, and/or treatment for alcohol and drug abuse.
អ Do not share sensitive information related to sexually transmitted infections, including HIV/AIDS, mental health
services, and treatment for alcohol and drug abuse with others.
Minors: A minor patient’s signature is required in order to release the following information: Conditions relating
to the minor’s reproductive health, sexually transmitted infection (if age 14 and older), alcohol and/or drug abuse, and
mental conditions (if age 13 and older).
Minor’s signature: Date:
By signing this page, I acknowledge that I have read and agree to the terms on both sides of this form.
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SCCA Medical Records Request
Why do
I need this form?
As required by law, Seattle Cancer Care Alliance (SCCA) complies with the Health Insurance Portability and Accountability Act
of 1996 (HIPAA). This includes protecting the confidentiality of your information. In certain situations, we need your written
permission to give your medical records to an outside facility/person, gather your medical records from an outside
facility/person, or talk with your family, friends, or others about your care. If you wish to give SCCA permission to do any of
these, please fill out the Medical Records Request form. You, as the patient, are not charged a fee for this.
If my health information is sent over email, how is it protected?
SCCA uses an email encryption service to ensure the confidentiality of the protected health information we send. SCCA also
uses the service to comply with federal regulations under HIPAA. For more information about SCCA’s Privacy Policy, please
visit our website at www.seattlecca.org/privacy-policy.
What is protected health information (PHI)?
PHI generally refers to demographic information (race, ethnicity, gender, age, etc.), medical histories, test and laboratory
results, mental health conditions, insurance information, and other data that a healthcare professional collects to identify an
individual and determine appropriate care.
Potential for my health information to be given to someone else:
Once SCCA gives your health information to another person or facility, the law does not always require the recipient to
maintain the confidentiality of your healthcare information.
What if I change my mind?
You may take away your permission to release your medical records by submitting a form to: SCCA Integrity Program, 825
Eastlake Ave East, M/S LG-600, P.O. Box 19023, Seattle, WA 98109 at any time. To get the form, email SCCA Integrity at
integrity@seattlecca.org.
If you take away your permission, it will not be effective if SCCA has already discussed, given, or
received information based on the original records release, or if SCCA requires the information in order to be paid for
treatment provided to you. You have the following rights:
• To inspect or to receive a copy of your protected health information
• To receive a copy of your signed records release
• To refuse to sign the records release
For questions about this process, please call the SCCA Integrity Program at 206-606-7154 or email integrity@seattlecca.org.
You also understand that giving SCCA permission to give or get your medical records is voluntary and is not meant to alter
your ability to receive care at SCCA, except if: (1) You are participating in research-related treatment, such as a clinical trial;
(2) SCCA is giving your PHI to a third party who has authorization.
Wher
e do I send my completed form?
Submit your completed Authorization Form to the SCCA clinic that provides your care using the contact information below.
You can send the form via email, fax, regular mail, or in person at the clinic that provides your care. Feel free to call the phone
numbers listed with any questions.
SCCA South Lake Union
SCCA at
UWMC - Northwest
SCCA at EvergreenHealth
SCCA at Overlake Medical
Center
Health Information
Management
PO Box 19023
MS: CE2-210
Seattle, WA 98109
Ph: (206) 606-1114
Fax: (206) 606-1035
release@seattlecca.org
Health Information
Management
1560 N 115
th
St.
Suite G16
Seattle, WA 98133
Ph: (206) 606-2794
Fax: (206) 606-6855
nwhhimfax@seattlecca.org
Health Information
Management
12040 NE 128
th
St.
MS: 98, Suite 1600
Kirkland, WA 98024
Ph: (425) 441-2644
Fax: (206) 606-8291
evgrelease@seattlecca.org
Health Information
Management
1135 116
th
Ave NE
Suite 250
Bellevue, WA 98004
Ph: (425) 635-6935
Fax: (425) 990-5309
belrelease@seattlecca.org
SCCA Issaquah
SCCA Peninsula
Health Information
Management
1740 NW Maple St. Suite 211
Issaquah, WA 98027
Ph: (206) 606-7907
Fax: (206) 606-4030
isqrelease@seattlecca.org
Health Information
Management
19917 Seventh Ave Suite 100
Poulsbo, WA 98370
Ph: (360) 697-8000
Fax: (206) 606-5122
pccrelease@seattlecca.org
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Completed 1 March 2021

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