[{"data":1,"prerenderedAt":-1},["ShallowReactive",2],{"detail-sidebar-cat-1-en-105":3,"doc-seo-194901-105":53,"doc-detail-194901-en":126},{"code":4,"msg":5,"data":6},0,"success",[7,14,19,24,29,34,39,44,49],{"id":8,"doc_module":9,"doc_module_name":10,"category_name":11,"show_sort_weight":12,"slug":13},11,1,"Template","Presentations",90,"presentations",{"id":15,"doc_module":9,"doc_module_name":10,"category_name":16,"show_sort_weight":17,"slug":18},12,"Resumes",80,"resumes",{"id":20,"doc_module":9,"doc_module_name":10,"category_name":21,"show_sort_weight":22,"slug":23},14,"Invoices",70,"invoices",{"id":25,"doc_module":9,"doc_module_name":10,"category_name":26,"show_sort_weight":27,"slug":28},15,"Posters",60,"posters",{"id":30,"doc_module":9,"doc_module_name":10,"category_name":31,"show_sort_weight":32,"slug":33},16,"Social Media",50,"social-media",{"id":35,"doc_module":9,"doc_module_name":10,"category_name":36,"show_sort_weight":37,"slug":38},17,"Forms",40,"forms",{"id":40,"doc_module":9,"doc_module_name":10,"category_name":41,"show_sort_weight":42,"slug":43},18,"Letters",30,"letters",{"id":45,"doc_module":9,"doc_module_name":10,"category_name":46,"show_sort_weight":47,"slug":48},21,"Paper Templates",5,"papers-templates",{"id":50,"doc_module":9,"doc_module_name":10,"category_name":51,"show_sort_weight":4,"slug":52},158,"General","general-158",{"code":4,"msg":54,"data":55},"ok",{"site_id":56,"language":57,"slug":58,"title":59,"keywords":60,"description":61,"schema_data":62,"social_meta":119,"head_meta":121,"extra_data":123,"updated_unix":125},105,"en","authorization-request","Authorization Request","","This document is an authorization request form for releasing medical and billing records. It specifies patient contact information, address, and former names. The form allows authorization for the release of various medical records, including but not limited to, sexually transmitted diseases, HIV/AIDS, behavioral health, and substance abuse treatment. It also provides options to authorize the release of specific sub-sections such as Sexual Assault Nurse Examination Records, Harborview Abuse and Trauma Center Records, Living Donor Records, and Hall Health Mental Health Records. The form includes a section for verbal communication authorization and requires the patient's or authorized person's signature and date.",{"@graph":63,"@context":118},[64,80,101],{"@type":65,"itemListElement":66},"BreadcrumbList",[67,71,74,77],{"item":68,"name":69,"@type":70,"position":9},"https://docshare.wps.com","Home","ListItem",{"item":72,"name":10,"@type":70,"position":73},"https://docshare.wps.com/template/",2,{"item":75,"name":36,"@type":70,"position":76},"https://docshare.wps.com/template/forms/",3,{"item":78,"name":59,"@type":70,"position":79},"https://docshare.wps.com/template/authorization-request/194901/",4,{"url":78,"name":59,"@type":81,"image":82,"author":87,"headline":59,"publisher":90,"fileFormat":93,"inLanguage":57,"description":61,"dateModified":94,"datePublished":95,"encodingFormat":93,"isAccessibleForFree":96,"interactionStatistic":97},"DigitalDocument",{"url":83,"@type":84,"width":85,"height":86},"https://docshare.wps.com/thumbnails/authorization-request/194901.png","ImageObject",442,249,{"name":88,"@type":89},"supergirl","Person",{"url":68,"name":91,"@type":92},"DocShare","Organization","application/pdf","2026-10-06","2026-09-03",true,{"@type":98,"interactionType":99,"userInteractionCount":79},"InteractionCounter",{"@type":100},"ViewAction",{"@type":102,"mainEntity":103},"FAQPage",[104,110,114],{"name":105,"@type":106,"acceptedAnswer":107},"What information can be released with this authorization?","Question",{"text":108,"@type":109},"This authorization permits the release of medical and billing records. It specifically allows for information related to sexually transmitted diseases, HIV/AIDS, behavioral or mental health services, and treatment for alcohol and drug abuse to be disclosed.","Answer",{"name":111,"@type":106,"acceptedAnswer":112},"What if I only want specific medical records released?",{"text":113,"@type":109},"The form provides an optional section to check specific units from which medical records can be released, including Sexual Assault Nurse Examination Records, Harborview Abuse and Trauma Center Records, Living Donor Records, and Hall Health Mental Health Records. However, records directly related to your care from these units are excluded by default unless you make a selection.",{"name":115,"@type":106,"acceptedAnswer":116},"Can I authorize verbal communication of my medical history?",{"text":117,"@type":109},"Yes, there is an option to authorize verbal communication only about your medical history and care.","https://schema.org",{"og:url":78,"og:type":120,"og:title":59,"og:site_name":91,"og:description":61},"article",{"robots":122,"canonical":78},"index,follow",{"doc_id":124,"site_id":56},194901,1788443766,{"code":4,"msg":5,"data":127},{"doc_id":124,"user_id":128,"nickname":88,"user_avatar":129,"doc_module":9,"category_id":35,"category_name":36,"doc_title":59,"doc_description":61,"doc_content":130,"file_id":131,"file_url":132,"file_type":133,"file_size":134,"view_count":135,"is_deleted":4,"is_public":9,"is_downloadable":9,"audit_status":9,"page_count":76,"language":136,"language_code":57,"site_id":56,"html_lang":57,"table_of_contents":137,"faqs":138,"seo_title":139,"seo_description":61,"update_tm":125,"read_time":9},962088121634,"https://ap-avatar.wpscdn.com/davatar_9964176cb1d06d4a9deccf72a44ae3dc","| Name– Last, First, MI | Birthdate | Phone |  |\n| --- | --- | --- | --- |\n| Street Address | City | State | Zip |\n| Email Address | Former Name(s)/Alias |  |  |\n\n\n| Name | Attention To | Phone | Fax | Email |  |\n| --- | --- | --- | --- | --- | --- |\n| Street Address |  | City |  | State | Zip |\n\n\n| 􀁆 Medical Records 􀁆 Billing Records 􀁆 Immunizations 􀁆 Radiology Images\u003Cbr>􀁆 Clinic Notes 􀁆 Labs and Pathology 􀁆 Procedures 􀁆 Radiology Reports\u003Cbr>􀁆 Other (please specify):  \u003Cbr>􀁆 AND/OR: I authorize VERBAL COMMUNICATION ONLY about my medical history and care. |\n| --- |\n| This authorization permits UW Medicine to release information related to sexually transmitted diseases, HIV/AIDS/AIDSrelated illnesses, behavioral or mental health services, and treatment for alcohol and drug abuse. |\n| *Optional* Please check below if you would like medical records from these units released. Medical records directly related to your care from these units are excluded by default, but some information may be released even if you do not make a selection if referenced elsewhere in your chart. This section does not apply to billing records.\u003Cbr>􀁆 Sexual Assault Nurse Examination Records 􀁆 Harborview Abuse and Trauma Center Records\u003Cbr>􀁆 Living Donor Records 􀁆 Hall Health Mental Health Records |\n\n\n| Signature (Patient or Person Authorized to Give Authorization) | Date |\n| --- | --- |","cbCaiohMYcjgWOBT","https://ap.wps.com/l/cbCaiohMYcjgWOBT","pdf",589955,8,"English","# Patient Information\n## Address and Contact\n## Former Names\n# Recipient Information\n## Contact Details\n# Authorization Details\n## Medical Records Release\n## Specific Unit Records (Optional)\n## Verbal Communication\n# Signature and Date","[{\"question\":\"What information can be released with this authorization?\",\"answer\":\"This authorization permits the release of medical and billing records. It specifically allows for information related to sexually transmitted diseases, HIV/AIDS, behavioral or mental health services, and treatment for alcohol and drug abuse to be disclosed.\"},{\"question\":\"What if I only want specific medical records released?\",\"answer\":\"The form provides an optional section to check specific units from which medical records can be released, including Sexual Assault Nurse Examination Records, Harborview Abuse and Trauma Center Records, Living Donor Records, and Hall Health Mental Health Records. However, records directly related to your care from these units are excluded by default unless you make a selection.\"},{\"question\":\"Can I authorize verbal communication of my medical history?\",\"answer\":\"Yes, there is an option to authorize verbal communication only about your medical history and care.\"}]","Authorization Request | PDF"]