Medical Records & Privacy Information

For information about how medical/health information about you may be used and disclosed, and how you can get access to this information, please read the following documents:

Privacy Information

Notice of Health Information Practices (Russian)
Извещение о практике соблюдения конфиденциальности
Notice of Health Information Practices (Spanish)
Aviso sobre Prácticas de Privacidad

Medical Records Release Form

Authorization for Release of Medical Information
Use this form to request a copy of your medical records or to request that another healthcare facility send your medical records to The Everett Clinic. Also available in Russian and Spanish language versions.
Authorization Cancellation Notice
Patients use this form to revoke/cancel their Authorization for Release of Medical Information form. Available in English.

Proxy Consent

Adult Proxy Consent Agreement
Proxy access allows a parent (or guardian) to log into their personal medical record account, and then connect to information regarding their family member. Complete the Proxy Consent Form and return it to our Medical Records department to request access to this convenient service.
Child Proxy Consent Agreement (Spanish)
MyChart Formulario para el apoderado del niño
Adult Proxy Consent Agreement (Russian)
ФОРМА ДЛЯ ПРЕДСТАВИТЕЛЯ ВЗРОСЛОГО ПАЦИЕНТА НА САЙТЕ MYCHART
Child Proxy Consent Agreement
Proxy access allows a parent (or guardian) to log into their personal medical record account, and then connect to information regarding their family member. Complete the Proxy Consent Form and return it to our Medical Records department to request access to this convenient service.
Adult Proxy Consent Agreement (Spanish)
MYCHART FORMULARIO PARA EL APODERADO DE UN ADULTO
Child Proxy Consent Agreement (Russian)
Форма для представителя ребенка на сайте

Other Forms

Authorization to Treat a Minor
Use this form if someone other than a parent is bringing a child into The Everett Clinic for medical treatment. This form can only be used for established Everett Clinic patients

Contact information

Our Health Information Management representatives are available to assist you with your medical record requests and related questions Monday through Friday, 7 am to 8 pm by calling (425) 339-5426 For your convenience you may also fax record requests directly to (425) 339-5439.