Form Date: 02/17/17 Page 1 of 1 Authorization for Use and Disclosure of
Inmate Records Information
Yakima County Department of Corrections
Authorization for Use and Disclosure of Inmate Records Information
Non-Medical Records – RCW 70.48.100
1. My Authorization:
Yakima County may use or disclose the following Inmate Jail Records (initial all that apply):
Yakima County may disclose the above records information to:
Name (or title) and organization:
Reason(s) for this authorization:
90 days from the date signed
when the following event occurs:
(no more than 90 days from date signed)
2. My Rights:
I may revoke this authorization in writing. A revocation would not affect any actions already taken by
YakimaCounty based upon this authorization. I may not be able to revoke this authorization if its
purpose was to obtain insurance. Two ways to revoke this authorization are: (1) fill out a revocation
form, available from Yakima County; or (2) write a letter requesting revocation to Yakima County.
I understand that information used or disclosed based on this authorization may be subject to re-
disclosure and no longer protected by federal privacy standards.
I hereby declare under the penalty of perjury pursuant to the laws of the State of Washington that I am
either the inmate or a representative of the inmate lawfully entitled to obtain records on the inmate’s behalf.
Signature of inmate or legally authorized representative
Printed name of signatory
Inmate records as specified: (please use the back of this form if additional space is needed)
All records in the Yakima County Jail concerning my incarceration on the following date(s):
