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Requests for Patient Records

Requests for information about drug and alcohol patient records will need to include a release of confidential information form that meets the requirements of federal regulations on Confidentiality of Alcohol and Drug Abuse Patient Records found in Chapter 42, Part 2, of the Code of Federal Regulations, or a proper court order.  Closed treatment agencies usually maintain their own closed client files.  DBHR maintains some closed client files from closed agencies.

To find out who the Patient Record Custodian is for closed agencies, contact darrel.streets@dshs.wa.gov or 360-725-3819.

Authorization DSHS 17-063 - Use this form when you want DBHR/DSHS to release of your confidential patient/client information to another party. If you believe that DBHR has archived your closed client/patient file due to a treatment agency closing, call before sending the form.  Most treatment agencies appoint a records custodian to maintain their records when closing, or they maintain their own records. 
       
Release of Confidential Information Use this form to request a certified treatment agency to send your records to another party.  This is a Sample fill-in form (HIPAA & 42 CFR Part 2 compliant).  Do not use this form for records held by DSHS.  The requirement that the patient's revocation be in writing was removed from this form per the recommendation of the Legal Action Center.