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

Medical Records Release Form

Authorization for Release of Medical Information
Use this form to request a copy of your medical records.

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
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.
Proxy for Release of Medical Information
This is an authorization that will permit The Everett Clinic to release your medical information to your designated adult proxy.

Other Forms

Friends & Family Form
Consent to leave messages/share information with family and friends
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