Medical Records & Privacy Information for Patients

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

Summary: Understanding Your Health Record/Info.

Notice of Health Information Practices for The Everett Clinic

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

The Everett Clinic: For the whole you.