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Release of Information – Minor Signature

Note
If the patient is a minor, between the ages of 13-17 years old, or who meets any of the criteria below, they will need to add their signature to this form. Otherwise, we have successfully received your response and you may close this window.
Release of Information of a Minor
Under Washington State Law, minors have the right to consent to certain health care treatment and release of records. Please have the patient sign this form if they meet any of the following requirements:
- If the patient is 13 years and older
- For birth control and pregnancy-related care - Any age
- For mental health records – 13 years and older
- For sexually transmitted diseases, including HIV – 14 years and older
- If the minor is legally emancipated (legally independent) or married to someone at or above age 18
- For outpatient drug and alcohol abuse treatment -13 years and older
Name of Patient:
First Name*
Last Name*
Email
Date*
MM slash DD slash YYYY

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